What types of wounds should not be irrigated?
wounds without a known endpoint (fistula)
what is wound irrigation
the application of fluid to a wound with the aim of removing exudate, debris, bacterial contaminants and dressing residue without causing adverse impact on the cellular activity of the wound healing process
What solutions can wounds be irrigated with
-sterile NS
-sterile water
-potable water
-commercial cleansing agents
-topical antiseptic agents
what psi does a irrigation tip allow
7-8
what are the characteristics of a wound irrigation tip
latex free, single use, disposable
when are wound irrigation tips used
used for deep wounds with/without the presence of tunneling
what size syringe should the nurse fill when irrigating a wound
a 20-30 mL syringe
If the nurse is irrigating a wound with a wide opening using a irrigation tip, how close should they hold the irrigation tip
2.5 cm above upper end of the wound
If the nurse is irrigating a wound with a small opening or tunneling wound using a irrigation tip, how close should they hold the irrigation tip
the tip should be inserted 1cm into the wound
what are the steps of wound irrigation
- using sterile technique, fill 20-30ml syringe with ordered irrigated fluid.
- attach tip to syringe
- hold tip 2.5 cm for wide opening wounds, 1cm deep for small opening wounds and flush using continuous pressure.
- repeat irrigation for prescribed amount (100ml usually) or until returns are clear
what is a sinus tract (tunneling)
a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue resulting in dead space and the potential of abscess formation
what is undermining
- is when a wound extends into the subcutaneous tissue under the skin.
- this is not allows visible from the surface meaning the actrual tissue damage can be substantially larger than it appears
what are causes of undermining wounds
infection, pressure ulcers, improper wound care
When should the nurse pack a wound?
- when their is a order
- when a wound is deep, tunnels, or has a sinus tract.
what does packing material do for wounds
- absorbs excess moisture, drainage, exudate = faster healing times
- protects wound against trauma with movement
-prevents the wound from closing top to bottom
what is the golden rule of wound healing
From the bottom up
what is wound packing
the process of loosely filling a wound cavity or dead space with a prescribed packing material
when packing a wound, if the packing is ordered to be moistened, what should the nurse ensure
packing should be DAMP not WET
What are 6 key concepts the nurse should be aware of when packing wounds
- use only one piece of packing if possible.
- use largest possible size of packing. (if needed, tie packing together with sterile gloves).
- use only enough packing to fill the wound space (no buldging or stretching).
- packing should cover entire wound bed and edges (not healthy tissue).
- do not pack undermining or tracts greater than 15 cm of have unknown endpoints unless ordered by MD or wound clinician.
- keep track + document packing used.
what type of procedure is wound packing
sterile procedure!
what the nurse plan to do before beginning to pack a wound
assess and measure the wound
what the nurse is removing and using products for wound packing, what they be sure to do
keep track of supplies removed/placed for accurate documentation
when the nurse has finished packing a wound, what should they do with the end of the packing strip?
leave a “tail” of packing materal clearly visible in the wound bed or secured to the peri-wound skin using steri-strip or paper tape)
what should the nurse consider approx 30 minutes prior to wound packing
consider giving a analgesic as wound packing can be painful:(
