Chapter 4. Wound Care Show
Moist to Dry DressingA moist to dry dressing is a primary dressing that directly touches the wound bed, with a secondary dressing that covers the primary dressing. The type of wound dressing used depends not only on the characteristics of the wound but also on the goal of the wound treatment. Important: Ensure pain is well managed prior to a dressing change to maximize patient comfort. Checklist 37 outlines the steps for performing a moist to dry dressing change. Checklist 37: Moist to Dry Dressing Change
Wound Irrigation and PackingWound irrigation and packing refer to the application of fluid to a wound to remove exudate, slough, necrotic debris, bacterial contaminants, and dressing residue without adversely impacting cellular activity vital to the wound healing process (British Columbia Provincial Nursing Skin and Wound Committee, 2014). Any wound that has a cavity, undermining, sinus, or a tract will require irrigation and packing. Open wounds require a specific environment for optimal healing from secondary intention. The purpose of irrigating and packing a wound is to remove debris and exudate from the wound and encourage the growth of granulation tissue to prevent premature closure and abscess formation (Saskatoon Health Region, 2013). Depending on the severity of the wound, it can take weeks to months or years to complete the healing process. Packing should only be done by a trained health care professional and according to agency guidelines. Contraindications to packing a wound include a fistula tract, a wound with an unknown endpoint to tunnelling, a wound sinus tract or tunnel where irrigation solution cannot be retrieved, or a non-healing wound that requires a dry environment (Saskatoon Health Region, 2013). The type of packing for the wound is based on a wound assessment, goal for the wound, and wound care management objectives. The packing material should fill the dead space and conform to the cavity to the base and sides. It is important to not over-pack or under-pack the wound. If the wound is over-packed, there may be excessive pressure placed on the tissue causing pain, impaired blood flow, and, potentially, tissue damage. If the wound is under-packed and the packing material is not touching the base and the sides of the cavity, undermining, sinus tract, or tunnel, there is a risk of the edges rolling and abscess formation (British Columbia Provincial Nursing Skin and Wound Committee, 2014). The types of gauze used to pack a wound may be soaked with normal saline, ointment, or hydrogel, depending on the needs of the wound. Other types of packing material include impregnated gauze, ribbon dressing, hydro-fiber dressing, alginate antimicrobial dressing, and a negative pressure foam or gauze dressing. If using ribbon gauze from a multi-use container, ensure each patient has their own container to avoid cross-contamination (British Columbia Provincial Nursing Skin and Wound Committee, 2014). Additional guidelines to irrigating and packing a wound are listed in Table 4.6.
The health care professional chooses the method of cleansing (a squeezable sterile normal saline container or a 30 to 35 cc syringe with a wound irrigation tip catheter) and the type of wound cleansing solution to be used based on the presence of undermining, sinus tracts or tunnels, necrotic slough, and local wound infection. Agency policy will determine the wound cleansing solution, but sterile normal saline and sterile water are the solutions of choice for cleansing wounds and should be warmed to support wound healing. Undermining, sinuses, and tunnels can only be irrigated when there is a known endpoint. Do not irrigate undermining, sinuses, or tunnels that extend beyond 15 cm unless directed by a physician or nurse practitioner (NP). If fluid is instilled into a sinus, tunnel, or undermined area and cannot be removed from the area, stop irrigating and refer to a wound specialist or physician or NP. Checklist 38 outlines the steps for irrigating and packing a wound. Checklist 38: Wound Irrigation and Packing
Video 4.5Watch the video Wound Irrigation and Packing by Renée Anderson and Wendy McKenzie, Thompson Rivers University. The following links provide additional information about wound packing and wound measuring. Read this Procedure: Wound Packing PDF to learn more about wound packing procedure. Take this Wound Assessment course to learn more about wound measuring and assessment.
Which is an appropriate pressure for routine irrigation of a wound?Pressure is the key to effective irrigation. Too little pressure will fail to remove surface bacteria, which may lead to wound infection. Too much pressure can actually force surface bacteria into the wound bed, in addition to damaging delicate granulation tissue. Irrigation pressure should be between 4 and 15 psi.
When irrigating a wound what size syringe and Angiocatheter is used to provide the correct pressure?We found that a 20-ml syringe attached to an 18-gauge angiocatheter delivers a stream of irrigant to the surface at approximately 12 psi [Figure 1]. Using this knowledge, a simple device was constructed from materials easily found in the ward.
When irrigating a wound What is the proper pressure for safe removal of debris?Original Agency for Health Care Policy and Research (AHCPR) guidelines describe safe and effective irrigation pressures as being 4-15 psi, based on a series of different studies. Pressures greater than 15 psi may cause wound trauma and drive bacteria further into wounds.
How do nurses irrigate wounds?Hold the syringe about 1 inch above the wound and flush gently with continuous pressure until returned fluid is clear: Irrigation should be drained into the basin because it is a medium for bacterial growth and subsequent infection. Irrigation should not increase patient discomfort.
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