Wound Irrigation

Question 1

Pre-Procedure

Answer 1

Verified the health care provider’s orders. Reviewed the medical record for any issues that may hinder the procedure.

Performed hand hygiene

Provided for the patient’s privacy.

Introduced self to the patient and family.

Identified the patient using two identifiers.

Assessed pain status while explaining the procedure to the patient.

Explained the physician’s order, and described the insertion procedure to the patient.

Checked prior nursing notes for previous wound assessments.

Question 2

Wound Irrigation:

Answer 2

Formed a cuff on a waterproof biohazard bag, and placed it near the bed.

Pulled the tape parallel to the skin, toward the dressing, while holding down the uninjured skin. Pulled in the direction of any hair growth. If necessary, secured the patient’s permission to clip or shave the area according to agency’s policy. Removed any adhesive from the skin.

With a clean, gloved hand or forceps, removed the old dressing one layer at a time. Observed the appearance of any drainage. Discarded the outside dressing first. Worked slowly and carefully. Kept the soiled underside of the dressings out of the patient’s sight.

Folded the dressing so that the drainage was contained inside it, and removed gloves inside out. If the dressing was small, pulled one glove inside out over the dressing.