wound cleansing

Question 1

wound cleansing =

Answer 1

flushing and irrigation

application of fluid to a wound to remove exudate, debris, bacterial contaminants and dressing residue without adversely impacting cellular activity vital to the wound healing process

Question 2

indications:

Answer 2

indicated for all wounds undergoing moist wound healing

Question 3

contraindications:

Answer 3

1) non healable wounds that require a dry stable environment (wounds covered with stable hard, dry eschar or dry gangrene)

2) fistulas

3) wound in which cleansing solution cannot be retrieved

4) wounds with tunneling, undermining, or sinuses where an endpoint cannot be reached using a sterile 15cm/6 inch metal probe or cotton tipped applicator

refer to NP or physician for further direction

may gently cleanse visible exudate from wound bed and surrounding skin with moistened gauze

Question 4

types of solution:

Answer 4

1. sterile normal saline
2. sterile water
3. commercial wound cleanser
4. potable tap water
5. topical antiseptic solutions

Question 5

solution guidelines:

Answer 5

should be non toxic to human tissue

remain effective in presence of organic material

reduce number of micro organisms in wound

avoid sensitivity reactions and be widely available and cost effective

Question 6

potable tap water

Answer 6

water that is safe for consumption

acceptable in some situations

based on agency guidelines and/or direction from a wound clinician

do not use to cleanse wounds with undermining, sinuses, or tunnels

Question 7

topical antiseptic solutions:

Answer 7

chlorhexidine or betadine iodine

can be used on recommendation of physician or wound clinician

reserved for wounds that are non healable or those in which the local bacterial burden is of great concern than healing

Question 8

solutions of choice:

Answer 8

sterile normal saline
sterile water

should be at 20C in order to support wound healing

using a cool or cold cleansing solution to clean the wound can lower the wound temperature and delay healing

Question 9

when using multi-use bottles of sterile normal saline or sterile water:

Answer 9

bottle must be dated when opened

check the date if you are using a previously opened bottle

open bottles must be discarded after 24hrs

Question 10

aseptic technique:

Answer 10

limits transfer of microorganisms from one person to another by minimizing count and preventing cross contamination

includes:
- no touch technique
- clean technique

decision to use which is based on clinet’s clinical status, type of wound, goal of care, dressing procedure, agency policy

Question 11

sterile technique =

Answer 11

to prevent or reduce exposure to microorganisms

requires use of meticulous hand washing and use of sterile field, sterile tray, sterile instruments, sterile solutions, sterile dressings, and sterile gloves

nurse uses clean gloved hands to remove and discard old dressing - gloves are removed and hands are washed - new sterile gloves

Question 12

sterile field:

Answer 12

set up with the instruments in the center of sterile field, as the 2.5cm (1inch) border of the drape is not considered “sterile”

Question 13

no touch technique:

Answer 13

prevent or reduce exposure to microorganisms

use of meticulous hand washing and includes use of sterile field, sterile tray, sterile instruments, sterile solutions, sterile dressings or client specific dressings saved for up to 2 weeks using antiseptic technique

handles of instruments on outer 2.5cm (1 inch) border of sterile field with sterile end pointing towards center of sterile field

handles of instruments may be touched with clean gloves and would remain on edge of sterile drape when not in use

Question 14

difference between no touch and sterile technique:

Answer 14

use of sterile gloves for sterile technique