wk 10 wound irrigation Flashcards
starting w Kozier cleansing wounds
why should you use NS or lactated ringers to lean or irrigate wouds instead of other substances
Commercial wound cleansers often contain surfactants that help remove debris and may be useful in some circumstances. —by using physiological solns you ensure theres no fluid shift caused by osmotic gradients
dont sub skin cleanser for wound cleanser!!
why not use skin cleansers or antiseptic agents lik hydrogen peroxide
cytotoxic
temp of soln for cleansing
warm to body temp (put in hot water basin to warm to body temp)
freq to cleanse wounds
when to deviate from this and rationale
each drsg change
o If wound is clean, has little exudates, and reveals healthy granulation tissue, avoid repeated cleaning —unnec cleaning can delay wound healing by traumatizing newly produced, delicate tissue, dec the surface temperature of the wound, and removing exudates which may have bactericidal properties itself
what is approp PSI for wound cleansisng
what would you use to deliver this fluid?
o Use safe irrigation P to enhance wound cleansing 4psi-8psi (high p goes up to 15psi).
This can be generated by using either a 30-60ml syringe with #18-#19 gauge angiocath or a single use 100ml squeeze bottle
you cleanse a wound and notice it is wet still. do you dry it? what product should be used?
what should not be used and why?
o Avoid drying a wound after cleansing it. Dry skin around wound only —healing is improved when wound is moist. Healing is deterred in dry wounds
o Use gauze sqaures. Avoid cotton balls and other products that shed fibres onto the wound surface —fibres can get embedded in granulation tissue and can act as foci for infection. May also stim foreign body rxns, prolonging the inflm phase of healing and delaying the healing process.
when using syringe to cleanse how high above wound should it be
how to get irrigation soln into deep wound w narrow opening?
2.5cm
o Introduce the cleansisngsoln directly into wound w syringe, syringe and catheter or pulsed lavage device.
If pt has deep wound w narrow opening, attch soft catheter to syringe to permit the fluid to enter the wound. Irrigation hsouldnt cause injury to tissues or discomfort.
syringe sie and gauge to use for cleansing w minimal risk of injury?
alt to using syringe and how to use this?
o Often good to have 35mlsyringe with 19 gauge angiocatheter to facilitate optimal P for cleansisng with minimal risk for tissue injury.
If pts ambulatory they can use handheld shower, hold it 30cm from wound
what is high P irrigation? psi? syringe? benefits?
o High P irrigation is cleansing of debris filled wound w irrigating fluid delivered at 4-15psiw 35ml syringe and 19gauge angiocatheter.
Additional benefits are softening and loosening of adherent necrotic tissue and cleansing and removal o wound exudates
if pt has lg wound how can you remove surface bact and debris
Use whirlpool to remove bact and debris from surface of lg wounds
benefits of wound irrigation
o Wound irrigation promotes wound healing by removing debris from a wound surface, decbact counts, and loosening and removing eschar
WHAT IS NEC For irrigation before beginning
o Order for irrigation of open wound and type of soln (open wound irrigation needs order and type of soln)
o Assess wound, allergies (antiseptics, meds, tapes, drsg material), pain!!!! (they might want analgesic 30-45 before procedure)
Educate/explain.
irrigation how to pos pt and supplies to put under/near them
o Position pt for gravitational flow of irrigating soln over wound with wound vertical to collection basin and into collection receptacle.
o Place container of irrigant/cleansing soln in basin of hot water to warm to body temp
o Place passing or extra towel on bed under area where irrigation wil take place
is this a sterile or clean procedure? what ppe is nec
says sterile gloves (when the wound has wide opening or it is a deep wound with very small opening…looks like when its just shower you dont have to worry about that)
gown and goggle if splash or spray risk exists
procedure of wound irrigation
wide opening
pos pt for gravitational flow into collection basin and receptacle
warm soln
put towels under pt
ppe (sterile gloves)
o Irrigate wound with wide opening: by filling 35ml syringe w irrigation soln, holding 2.5cm above upper end of wound, and flushing wound w continuous P.
o Repeat until soln draining into basin is clear
o When indicated obtain cultures after cleansing w nonbacteriostatic saline (culture if wound has fould, purulent odour, inflm surrounds wound, nondraining wound begins to drain or pt is febrile
o Dry wound edges w gauze or if pt showered, dry them
o Apply drsg and label w time, date, nurse’s initials
irrigation for deep wound w small opening
o To irrigate deep wound w small opening:w soft catheter attached to irrigation syrninge insert into wound opening 1.3m and use slow, continuous P to flush.
o Keep catheter in place and pinch off just below syringe then remove and refill syring, reconnect and repeat until draining soln is clear
how to cleanse wound with handheld shower
o Cleanse handheld shower: hnd hygiene and gloves. Have pt seated in shower chair. Adjust spray to a gentle flow and make sure water is warm. Shower for 5-10mins w shower head 30cm from wound
what do you evaluate after irrigation
o Assess:pt pain, Inspect drsg periodically, has any irrigant been retained
what do if o Bleeding or serosanguineous drainage appear
-flush wound using less P next time. Notify dr.
what do if inc pain or disomfort appears
dec force of P during irrigation. Assess pt for analgesia before wound care
what do if suture lin opening extends
notify. Reeval amount of P to use next time for irrigation
what to record after irrigation
o Record wound assessment before and after irrigation;amount color and odor of drainage on drsg removed; amount and type of soln used; irrigation device used; pts tolerance of the procedure, type of drsg applied
when to immed report to dr
o Immed report to dr if evidence of fresh bleeding, sharp inc in pain, retention of irrigant, or signs of shock
what is gauze drsg good for
good for absorption. protection of surgical wounds. absorption of minimal to heavy exudate. Deliver soln to wound.
may adhere to healthy tissue and cause injury on removal
what type of drsg would be indicated for necrotic wound
what ype of wound is this not good for
hydrogel
not good for heavily exudating wound or infected ones
what kind of drsgs are good for mod-heavy wound exudate (they are good for absorption)
alginate, hydrogel, gauze
what drsgs are good for minimal to mod exudate
hydrocolloids
what drg is good for hemostasis
alginate
what drsg would be v bad for minmally exudative wound
foam. it mya promote wound dehydration and dessication if minimal exudate
drawback of hydrocolloids for assessing
they may leave residue and wound should be cleansed before asessment
what kind of drsgs are good for autolytic debridement
hydrocolloids and hydrogel
