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Skills

Wound Irrigation - CE/NCPD

Extended Text
The content in Clinical Skills is evidence based and intended to be a guide to clinical practice.
Always follow your organization’s practice.

ALERT

OVERVIEW
Wound cleansing using high-pressure irrigation promotes wound healing by removing debris and
exudate from the wound surface, reducing the
amount of surface bacteria and loosening Commonly used devices for cleansing and irrigating
adherent nonviable tissue. , wounds include bulb
syringes, syringes with angiocatheters or needles attached, and specialty high-pressure irrigation
devices. The three factors involved in wound irrigation are the solution, the pressure, and the volume
(Table 1).
Noncytotoxic solutions used for irrigation include a 0.9% sodium chloride solution and tap water.
Both are effective at wound cleansing, and subsequent wound infection rates after cleansing with
either of the two do not differ significantly. Antiseptic solutions may be used if the wound is
infected and should be discontinued once bacterial loads and volume of necrotic tissue in the wound
bed have decreased.
Low-pressure irrigation is defined as 1 to 2 psi. High-pressure irrigation is between 4 and 15 psi.
Both high- and low-pressure irrigation reduces levels of Staphylococcus aureus; however, higher
pressure is more effective at removing particles and debris. Wound lavage must be vigorous
enough to remove foreign material, decrease bacterial contamination, remove cellular debris, and
remove exudate from the surface of the wound. It should also be gentle enough to avoid further
tissue trauma or to further contaminate the wound by forcing bacteria and foreign matter deeper
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into the wound.
Cleansing a wound using a bulb syringe filled with tap water or a 0.9% sodium chloride solution
provides low pressure and can help remove surface debris and exudate. A 35-ml syringe with a 19-
G needle or soft angiocatheter attached is most often used and creates adequate pressure for wound
irrigation.
Wounds should be irrigated with a minimum of 200 ml of solution per square centimeter of wound
or until all debris has been removed.
Regular wound cleansing and irrigation is commonly used to manage delayed closure surgical
wounds healing by secondary intention (Figure 1) and other chronic wounds, such as pressure
injuries. The use of sterile technique for performing wound irrigation is appropriate for patients at
high risk for infection.

SUPPLIES
See Supplies tab at the top of the page.

EDUCATION
• Provide developmentally and culturally appropriate education based on the desire for
knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Teach the patient and family how to irrigate the wound, if applicable.

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• Observe the patient and family as they perform a return demonstration.

• Provide the family with written instructions.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment
1. Perform hand hygiene before patient contact. Don appropriate personal protective
equipment (PPE) based on the patient’s need for isolation precautions or the risk of
exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient for a history of allergies to antiseptics, medications, tapes, or dressing
materials.
5. Check the practitioner’s orders for topical wound care and irrigation, including the type of
irrigation solution prescribed.
6. Review the patient’s last documented wound assessment and compare it with the current
wound assessment.
7. Assess the patient’s comfort level using an organization-approved pain scale and identify
symptoms of anxiety.
Preparation
1. Administer pain medication, if ordered.
2. Reassess the patient’s pain status, allowing for sufficient onset of action per the

medication, route, and the patient’s condition. Assess for adverse reactions to the
medication (e.g., respiratory depression).
3. Determine the amount of irrigation solution needed and types of primary and secondary
dressings needed and gather the necessary supplies.
4. Close the room door or bed curtains.
5. Position the patient comfortably to permit the gravitational flow of irrigation solution over
the wound and into the collection receptacle (Figure 2).
Rationale: Positioning the patient to permit the gravitational flow of irrigation solution avoids
fluid retention in the wound by encouraging the flow of irrigant away from the wound.

Rationale: Absorbent padding or towels will absorb fluid and protect bed linens.

6. Place absorbent padding or towels on the bed.

7. Expose only the area of the wound.

8. Form a cuff on the waterproof biohazard bag and place the bag near the bed.

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Rationale: The hot water warms the solution to body temperature.

9. Place the container of irrigation solution in a basin of hot water.

PROCEDURE
1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need
for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.

4. Carefully remove the soiled dressing, if applicable.

5. Examine the dressing for quality (color, consistency) and quantity of drainage (saturated,
slightly moist, or no drainage).
6. Discard the dressing in a waterproof biohazard bag, remove gloves, and perform hand
hygiene. Don clean gloves.
7. Perform a wound assessment, noting whether the type of tissue in the wound bed is red, yellow,
or black (Table 2).
8. Obtain a wound culture specimen using a swab and an appropriate specimen container as
ordered or if signs of infection are noted.
a. Foul, purulent odor
b. Inflammation surrounding the wound

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c. Increased amount of exudate or drainage

d. Fever
9. Labelthe specimen(s) in the presence of the patient.
10. Place the labeled specimen(s) in a biohazard bag and transport it to the laboratory.

11. Remove PPE and perform hand hygiene.

Irrigating a Wound with a Wide Opening

1. Don sterile gloves, if indicated; otherwise, don gloves. Don additional PPE based on the
patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Fill a 35-ml syringe with irrigation solution.

3. Attach a 19-G angiocatheter or a 19-G blunt needle to the syringe. ,

Rationale: Avoiding contact with the wound prevents syringe contamination. Careful
placement of the syringe also prevents unsafe pressure of the flowing solution.

4. Hold the syringe above the upper end of the wound and over the area being irrigated.

Rationale: A clear solution indicates that all debris has been removed.

5. Using continuous pressure, flush the wound until the solution draining into the basin is clear.

Rationale: Drying the wound edges prevents maceration of the surrounding tissue from
excess moisture.

6. Dry the wound edges with gauze.

7. Reassess the wound, noting whether the type of tissue in the wound bed is red, yellow, or black
(Table 2).
8. Apply an appropriate dressing per practitioner’s order (Table 3).
9. Label the dressing.

10. Assist the patient to a comfortable position.

11. Dispose of all soiled dressings, supplies, or single-use equipment in a waterproof bag.
12. Remove PPE and perform hand hygiene.
13. Document the procedure in the patient’s record.

Irrigating a Deep Wound with a Small Opening

1. Don sterile gloves, if indicated; otherwise, don gloves. Don additional PPE based on the
patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Attach a soft catheter to a solution-filled irrigation syringe.
3. Gently insert the tip of the catheter into the wound opening.

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4. Using slow, continuous pressure, flush the wound until the solution draining into the basin is
clear.

Rationale: Drying the wound edges prevents maceration of the surrounding tissue from
excess moisture.

5. Dry the wound edges with gauze.

6. Reassess the wound, noting whether the type of tissue in the wound bed is red, yellow, or black
(Table 2).
7. Apply an appropriate dressing per practitioner’s order (Table 3).
8. Label the dressing.
9. Assist the patient to a comfortable position.
10. Dispose of all soiled dressings, supplies, or single-use equipment in a waterproof bag.
11. Remove PPE and perform hand hygiene.
12. Document the procedure in the patient’s record.

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MONITORING AND CARE

1. Assess, treat, and reassess pain.

Rationale: Monitoring the wound bed and periwound skin enables tracking of wound healing
progress and signs of infection.

2. Monitor the type of tissue in the wound bed and monitor the periwound skin integrity.

3. Periodically inspect the dressing to ensure that it remains intact and free of leakage or excessive
bleeding.

EXPECTED OUTCOMES
• The patient states or demonstrates an acceptable level of comfort.
• The wound demonstrates signs of healing.
• Amount of wound drainage and tissue inflammation decreases.
• Surrounding skin integrity is maintained.

UNEXPECTED OUTCOMES
• Bleeding
• Increased pain or discomfort
• Increased wound dimensions

DOCUMENTATION
• Wound assessment before and after irrigation
• Amount and color of drainage on the dressing removed
• Amount and type of irrigation solution used
• Irrigation device used
• Patient’s tolerance of the procedure
• Type of dressing applied after irrigation
• Date and time of dressing change
• Pain level and response to pain medications, if administered
• Education
• Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS
• Some children are frightened during wound irrigation and may try to prevent the nurse from
irrigating a wound. Allowing the child to take part in the procedure or using play therapy on a
doll with a wound may help the child work out feelings about the wound irrigation and may
encourage cooperation.

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• Neonatal skin is immature and is easily damaged from pressure and wound care products. A
neonate’s skin absorbs products readily. The nurse should ensure that products are approved
for use with neonates.

OLDER ADULT CONSIDERATIONS

• Wound irrigations may be traumatic, frightening, and painful for some older adults.
• Assess the older adult patient’s ability to cooperate before performing wound irrigation.
• Consider the older adult patient’s cognitive level when performing wound irrigation.

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REFERENCES
1. Brace, J.A. (2024). Chapter 20: Wound debridement. In R.A. Bryant, D.P. Nix (Eds.), Acute
& chronic wounds: Intraprofessionals from novice to expert (6th ed., pp. 430-440). St. Louis:
Elsevier.
2. European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel

(NPIAP), Pan Pacific Pressure Injury Alliance (PPPIA). (2019). Prevention and treatment of
pressure ulcers/injuries: Quick reference guide 2019. Retrieved April 11, 2024, from
https://internationalguideline.com/2019 (https://internationalguideline.com/2019)
3. Jaszarowski, K., Murphree, R.W. (2022). Chapter 9: Wound cleansing and dressing selection. In
L.L. McNichol, C.R. Ratliff, S.S. Yates (Eds.),
Wound, Ostomy, and Continence Nurses Society core curriculum: Wound management (2nd
ed., pp. 157-171). Philadelphia: Wolters Kluwer.
4. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program.
Retrieved April 11, 2024, from
https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-
goals/2024/npsg_chapter_hap_jan2024.pdf
(https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-
goals/2024/npsg_chapter_hap_jan2024.pdf )
5. Lammers, R.L., Aldy, K.N. (2019). Chapter 34: Principles of wound management. In J.R.
Roberts and others (Eds.), Roberts and Hedges’ clinical procedures in emergency medicine
and acute care (7th ed., pp. 621-654). Philadelphia: Elsevier.
6. Sepehripour, S., Dheansa, B.S. (2018). Wound irrigation and the lack of evidence-based
practice. Journal of Plastic, Reconstructive & Aesthetic Surgery, 71(6), 940-941.
doi:10.1016/j.bjps.2018.02.006
7. Tankersley, D., Schrobilgen, T. (2017). Pitfalls in wound management. Physician Assistant

Clinics, 2(3), 435-448. doi:10.1016/j.cpha.2017.02.007 Adapted from Perry, A.G. and others (Eds.).

(2025). Clinical nursing skills & techniques (11th ed.). St. Louis: Elsevier.

Clinical Review: Suzanne M.

Casey, MSN-Ed, RN

Published: May 2024

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