Administering a Tube Feeding 32-2 1

Administering a Tube Feeding32-2 1

NURsing Procedure 58-2

Performing a Sterile Wound Irrigation

SUPPLIES AND EQUIPMENT

✓Disposable sterile irrigation pack / ✓Eye shield or face guard
✓Sterile irrigation solution, as ordered / ✓Sterile dressings, as ordered
✓Marked biohazard bag / ✓Tape and other supplies needed to apply new dressing
✓Clean gloves / ✓Sterile gloves, if ordered
✓Waterproof bed pad / ✓Clean basin or irrigating pouch
✓Bath blanket

RECOMMENDED TECHNIQUEESNPComments

Follow LPN WELCOME steps and then
1.Put on clean gloves and an eye shield or face guard. /
2.Position the client so the solution will run from the upper end of the wound downward. Place the waterproof bed pad and clean basin or irrigating pouch under the area to be irrigated. /
3.Drape the client with a bath blanket to expose only the wound. /
4.Remove the used dressing and discard it as described in In Practice: Nursing Procedure 58-1. Discard gloves. Wash hands again. /
5.Open the irrigation tray, using sterile technique. Open the irrigation solution; place the cover on the table, with the inside facing upward. Carefully pour the solution from the supply bottle into the irrigation bottle. (Pour solution with the bottle label facing your palm.) If the bottle has been opened previously, pour off a small amount of the solution into a trash receptacle. Leave the cover off the irrigation supply bottle, with the inside of the cover pointing upward. /
6.Place the bottle close to the client on the overbed table. Date and initial the bottle after opening it. Include the client’s name and facility ID number. /
7.Open the sterile dressing tray, if one is to be used, and put on sterile gloves. /
8.Prepare the inside of the irrigation and dressing trays. Place the irrigation syringe into the bottle. Open dressing packages and prepare other items. /
9.Carefully assess the amount and character of drainage and the size and condition of the wound and surrounding tissue. /
10.While explaining the following steps to the client as you proceed, draw up solution into the syringe. /
11.Hold the syringe just above the wound’s top edge, and force fluid into the wound, slowly and continuously. Use sufficient force to flush out debris, but do not squirt or splash fluid. Irrigate all portions of the wound. Do not force solution into the wound’s pockets. Continue irrigating until the solution draining from the wound’s bottom end is clear. /

NURsing Procedure 58-2

Performing a Sterile Wound Irrigation(Continued)

RECOMMENDED TECHNIQUE(Continued)ESNPComments

12.Using sterile 4 × 4 pads, gently pat dry the wound’s edges (if the wound is to have a wet-to-dry dressing, then dry only the surrounding skin). Work from the cleanest to the most contaminated area. /
13.Apply sterile dressings as ordered. /
Follow ENDDD steps.
Special Reminder
•Teach the client or caregiver to observe for excess drainage, severe pain, redness, or hardness around the wound. Include any other pertinent observations. /

KEY: E = Excels S = Satisfactory NP = Needs Practice

Pass Fail

Student’s Signature:______Date: ______

Instructor’s Signature:______Date: ______