{"id":571,"date":"2018-06-05T12:28:31","date_gmt":"2018-06-05T16:28:31","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/4-6-moist-to-dry-dressing-and-wound-irrigation-and-packing\/"},"modified":"2019-09-30T13:13:23","modified_gmt":"2019-09-30T17:13:23","slug":"4-6-advanced-wound-care-wet-to-moist-dressing-and-wound-irrigation-and-packing","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/4-6-advanced-wound-care-wet-to-moist-dressing-and-wound-irrigation-and-packing\/","title":{"raw":"4.6 Advanced Wound Care: Wet to Moist Dressing, and Wound Irrigation and Packing","rendered":"4.6 Advanced Wound Care: Wet to Moist Dressing, and Wound Irrigation and Packing"},"content":{"raw":"Traditionally, when wounds required debridement wet to dry dressings were used. This involved applying moist saline or other solution (i.e., Dakin's) to gauze, placing it into a wound bed, allowing it to dry, and then removing it. As the dressing is removed, so is the unhealthy tissue. The belief was that the removal of the dead tissue facilitated healing. As we have come to understand more about wound healing, we now know that this practice disrupts healthy tissue. Besides being detrimental to wound healing, it can also be painful for the patient. As such, this is not current best practice (Kerr et al., 2014).\r\n\r\nWe have come to understand that wound beds need a moist environment to heal. Wet to moist dressings provide a moist healing environment, but they can require several dressing changes each day to maintain that moisture. These frequent dressing changes come with personal cost to the patient, financial cost in terms of nursing time and supplies, risk of infection associated with frequent dressing changes, and potential damage to the wound bed if the dressing is allowed to dry out (Kerr et al., 2014).\r\n\r\nA wet to moist dressing can be selected for a wound bed until further direction is given by someone with knowledge about wound products. The type of wound dressing used depends not only on the characteristics of the wound, but also on the goal of the wound treatment and ability to access products. Recalling factors that influence wound healing, the skill and knowledge of the healthcare professional (HCP) and their ability to diagnose, select appropriate treatments, and correctly implement treatments are important considerations in relation to wound care\u00a0 (Norton et al., 2018; Harris et al., 2018).\r\n

Wet to Moist Dressing<\/h2>\r\nA\u00a0wet to moist dressing involves a primary dressing that directly touches the wound bed, and a secondary dressing covering it.\r\n\r\nImportant<\/strong>: Ensure pain is well managed prior to a dressing change to maximize patient comfort.\r\n\r\nChecklist 36 outlines the steps for performing a wet to moist dressing change.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
\r\n

<\/a>Checklist 36: Wet to Moist Dressing Change<\/h3>\r\n
Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n

\r\n
Safety considerations:<\/span><\/h5>\r\n
\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. Check present dressing using\u00a0non-sterile gloves if necessary.<\/td>\r\nThis provides an opportunity for assessment and to determine required supplies for the procedure.<\/td>\r\n<\/tr>\r\n
2. Perform hand hygiene.<\/td>\r\nHand hygiene reduces the risk of infection.\r\n\r\n[caption id=\"attachment_5083\" align=\"aligncenter\" width=\"150\"]\"Perform<\/a> Perform hand hygiene[\/caption]<\/td>\r\n<\/tr>\r\n
3. Gather necessary equipment and supplies.<\/td>\r\nBeing organized will help with efficiency and expedite the procedure, minimizing the length of time the patient experiences discomfort.<\/td>\r\n<\/tr>\r\n
4. Prepare environment; position patient; adjust height of bed; turn on lights; and sanitize working surface.<\/td>\r\nThis helps prepare patient and bedside for procedure.<\/td>\r\n<\/tr>\r\n
5. Perform hand hygiene.<\/td>\r\nHand hygiene reduces the risk of infection.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]\"Hand<\/a> Hand hygiene with ABHR[\/caption]<\/td>\r\n<\/tr>\r\n
6. Decide if this is a clean or sterile procedure. If a clean procedure, use non-sterile gloves. If a sterile procedure, use sterile gloves and follow principles of asepsis.\r\n\r\nPrepare field.<\/td>\r\n\r\n\r\n[caption id=\"attachment_4753\" align=\"aligncenter\" width=\"150\"]\"Sterile<\/a> Sterile field[\/caption]\r\n\r\nWhether this is a sterile or clean procedure, always reduce risk of transmitting microorganisms to patients<\/td>\r\n<\/tr>\r\n
7. Add necessary sterile supplies. If this is a sterile procedure, use sterile saline.\r\n\r\nIf you are irrigating the wound, you will need irrigation equipment (10 ml syringe and wound irrigation catheter).<\/td>\r\n\r\n\r\n[caption id=\"attachment_4757\" align=\"aligncenter\" width=\"150\"]\"Adding<\/a> Add supplies[\/caption]<\/td>\r\n<\/tr>\r\n
8. Pour cleansing solution into two separate compartments.\r\n\r\nPlace gauze and saline to be used for wound packing in its own compartment.<\/td>\r\n\r\n\r\n[caption id=\"attachment_4749\" align=\"aligncenter\" width=\"150\"]\"Pouring<\/a> Pour cleansing solution[\/caption]<\/td>\r\n<\/tr>\r\n
9. Apply non-sterile gloves.<\/td>\r\nThis reduces the risk of contaminating your\u00a0hands with the patient's blood and other body fluids.\r\n\r\nIt also\u00a0reduces the risk of germ transmission from you to the patient and vice versa, as well as from one patient to another.\r\n\r\n[caption id=\"attachment_5561\" align=\"aligncenter\" width=\"150\"]\"Apply<\/a> Apply non-sterile gloves[\/caption]<\/td>\r\n<\/tr>\r\n
10.\u00a0Remove outer dressing with non-sterile gloves.<\/td>\r\n\r\n\r\n[caption id=\"attachment_4701\" align=\"aligncenter\" width=\"150\"]\"Removing<\/a> Remove outer dressing with non-sterile gloves[\/caption]<\/td>\r\n<\/tr>\r\n
11.\u00a0Remove inner dressing with transfer forceps, and assess the old dressing and the wound.<\/td>\r\n\r\n\r\n[caption id=\"attachment_553\" align=\"aligncenter\" width=\"150\"]\"Remove<\/a> Remove inner dressing with forceps[\/caption]\r\n\r\nInspect wound\u00a0for evidence of healing or complications including the amount and type of drainage, odor, presence of staples \/ sutures, wound approximation, peri skin condition.<\/td>\r\n<\/tr>\r\n
12.\u00a0Discard transfer forceps and non-sterile gloves.<\/td>\r\n\r\n\r\n[caption id=\"attachment_5878\" align=\"aligncenter\" width=\"150\"]\"Discard<\/a> Discard transfer forceps[\/caption]<\/td>\r\n<\/tr>\r\n
13. Drape patient with underpad (optional).<\/td>\r\n\r\n\r\n[caption id=\"attachment_5881\" align=\"aligncenter\" width=\"150\"]\"Drape<\/a> Drape patient with underpad[\/caption]<\/td>\r\n<\/tr>\r\n
14. Clean the peri-wound skin and clean the wound bed either by irrigating or with sterile gauze and saline.<\/td>\r\nIrrigating with 10 pounds per square inch (PSI) and\/or wiping gently with sterile gauze helps to lift slough and clean the wound bed.<\/td>\r\n<\/tr>\r\n
15. Apply sterile or clean gloves (depending if the nature of the wound calls for a clean or sterile procedure).\r\n\r\nWring-out excess solution from the gauze to be used for packing.\r\n\r\n\"Not too wet and and not too dry ... just like your eye\" (author unknown)<\/td>\r\nUse enough saline to saturate gauze. Too much moisture can cause the peri-wound skin to become macerated.\r\n\r\n[caption id=\"attachment_6216\" align=\"aligncenter\" width=\"150\"]\"Saturate<\/a> Saturate gauze[\/caption]<\/td>\r\n<\/tr>\r\n
16. Fluff up the moist gauze. Place into wound ensuring the wound bed is in contact with the moisture. Ensure gauze does\u00a0not touch peri-wound skin.<\/td>\r\nApply skin preparation to peri-wound skin if there is risk of skin breakdown.\r\n\r\n <\/td>\r\n<\/tr>\r\n
17. Apply cover dressing. Secure with tape, stockinette, or\u00a0 kling.<\/td>\r\nSelect a cover dressing that will help the gauze to remain moist until the next dressing change (i.e., one that won't wick away all of the moisture and cause the gauze to dry out).<\/td>\r\n<\/tr>\r\n
18. Discard gloves according to agency policy, and\u00a0perform hand hygiene.<\/td>\r\nHand hygiene reduces the risk of infection.\r\n\r\n[caption id=\"attachment_5945\" align=\"aligncenter\" width=\"150\"]\"Book<\/a> Discard gloves[\/caption]<\/td>\r\n<\/tr>\r\n
19. Next:\r\n
    \r\n \t
  • Assist patient to comfortable position.<\/li>\r\n \t
  • Lower patient\u2019s bed.<\/li>\r\n \t
  • Discard used equipment appropriately.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
These steps ensure the patient's continued safety.<\/td>\r\n<\/tr>\r\n
20. Document procedure and\u00a0findings according to agency policy.\r\n\r\nReport any unusual findings or concerns to the appropriate healthcare professional.<\/td>\r\nRecord dressing change:\u00a0time, place of wound, wound characteristics, presence of staples or sutures, size, drainage type and amount, type of cleansing solution and dressing applied.\r\n\r\n \r\n\r\nSample charting:\r\n\r\ndate \/ time.\u00a0Right\u00a0lateral ankle dressing changed. Large amount\u00a0of sero purulent drainage. No odor. Wound approx 2 cm \u00d7 3 cm \u00d7 0.5 cm. Wound bed 90 % yellow slough 10% red. Irrigated with 30 ml normal saline. Packed with 4\u00d74 gauze moist with saline. Covered with ABD pad and secured with stockinette. Peri-wound skin intact. Tolerated well.\u00a0 ---------------T Rex RN<\/em><\/td>\r\n<\/tr>\r\n
Data sources:\u00a0Perry et al., 2018;\u00a0WHO, 2009<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

Wound Irrigation and Packing<\/h2>\r\nWound irrigation and packing refer to\u00a0the 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, 2017).\r\n\r\nAny wound that has a cavity, undermining, sinus, or a tract will require irrigation and packing. Open wounds require a specific environment for optimal healing\u00a0from 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 healthcare professional and according to agency guidelines.\r\n\r\nContraindications to packing a wound include a fistula\u00a0tract,\u00a0a wound with an unknown endpoint to tunneling, 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).\r\n\r\nThe 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).\r\n\r\nThe 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 gauze impregnated with polyhexaamethylene biguanide (PHMB), iodine (povidone and cadexomer), ribbon dressing, hydro-fiber dressing, alginate antimicrobial dressing, and a negative pressure foam or gauze dressing. Table 4.7 lists some wound care products and indications for each. 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,\u00a02014).\r\n\r\nAdditional guidelines to irrigating and packing a wound are listed in Table 4.8.\r\n

Wound Care Products<\/h2>\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
\r\n

Table 4.7 Wound Care Products<\/h3>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Type<\/h4>\r\n<\/td>\r\n

\r\n

Indications<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

Non-adherent contact layer (i.e., Telfa, silicone, petroleum-based woven dressings)<\/td>\r\nAllows the wound to drain with minimal disruption to the wound bed when the dressing is removed. Requires an outer dressing.<\/td>\r\n<\/tr>\r\n
Hydrocolloid<\/td>\r\n\r\n
    \r\n \t
  • Minimal absorption capability (not for highly draining wounds)<\/li>\r\n \t
  • Good for autolytic debridement<\/li>\r\n \t
  • Maintains moist wound bed<\/li>\r\n \t
  • Impermeable to external contamination<\/li>\r\n \t
  • Self-adhesive and pliable, so conforms to the body<\/li>\r\n \t
  • Duration approx. 5 to 7 days<\/li>\r\n \t
  • All gel must be removed between dressing changes<\/li>\r\n \t
  • Not for infected or necrotic wounds<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Hydrogel<\/td>\r\n\r\n
    \r\n \t
  • Introduces moisture into the wound<\/li>\r\n \t
  • Absorbs small amounts of exudate<\/li>\r\n \t
  • Debrides wound by softening necrotic tissue<\/li>\r\n \t
  • Does not adhere to wound base<\/li>\r\n \t
  • Duration approx. 5 to 7 days<\/li>\r\n \t
  • All gel must be removed between dressing changes<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Calcium alginates<\/td>\r\n\r\n
    \r\n \t
  • Manufactured from seaweed<\/li>\r\n \t
  • Highly absorbent<\/li>\r\n \t
  • Becomes a gel in presence of moisture<\/li>\r\n \t
  • Available as sheet or rope form<\/li>\r\n \t
  • Requires an outer dressing<\/li>\r\n \t
  • Must be fitted to the wound bed and not in contact with peri-wound skin<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Foams<\/td>\r\n\r\n
    \r\n \t
  • Used for highly draining wounds<\/li>\r\n \t
  • Autolytic debridement<\/li>\r\n \t
  • Change frequency depends on wound drainage (1 to 3 days)<\/li>\r\n \t
  • Not for infected wounds<\/li>\r\n \t
  • Not for dry necrosis<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Charcoal<\/td>\r\n\r\n
    \r\n \t
  • Charcoal imbedded in product and is odour absorbent<\/li>\r\n \t
  • Requires an outer dressing<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Anti-microbials<\/td>\r\n\r\n
    \r\n \t
  • Medical grade honey, silver, cadexomer iodine, alginates, foams, pastes<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Negative Pressure Wound Therapy (NPWT)<\/td>\r\n\r\n
    \r\n \t
  • Also knows as VAC dressing, vacuum assisted closure<\/li>\r\n \t
  • Manages large amounts of exudate<\/li>\r\n \t
  • Sub-atmospheric pressure applied to a wound bed promotes and accelerates healing<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
BHMB<\/td>\r\n\r\n
    \r\n \t
  • Antimicrobial \/ antiseptic impregnated into guaze (strips or sheets) and foam dressings<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Silver impregnated gauze \/ foams<\/td>\r\n\r\n
    \r\n \t
  • \u00a0Silver is antimicrobial and promotes healing. Foam absorbs moisture<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Combination products<\/td>\r\n\r\n
    \r\n \t
  • Can include more than one of the above (e.g., silver and charcoal)<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Data sources: Alavi et al., 2015; Eberlein & Assadian, 2010; Kerr et al., 2014; Munteanu et al, 2016; Wiegand et al., 2015<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
\r\n

Table 4.8 General Guidelines for Irrigating and Packing a Complicated Wound<\/h3>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Guideline<\/h4>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

Aseptic technique<\/td>\r\nSterile technique or no-touch technique may be used for irrigating and packing a wound. The use of a specific technique is based on agency policy, condition of the client, heal-ability of the wound, invasiveness, and goal of the wound care. Sterile technique or no-touch technique must be used in all acute care settings. Clean technique may be used for chronic wounds in long-term-care and home settings.<\/td>\r\n<\/tr>\r\n
Type of solution for irrigation<\/td>\r\nThe most common solution used is normal saline at room temperature, unless otherwise ordered. Check prescriber's \/ wound care specialist's orders.\r\n\r\nNon-potable water should never be used for cleansing of post operative wounds. Boiled and cooled water is an acceptable alternative (Johanna Briggs Institute, 2006, as cited in Harris et al., 2018)<\/td>\r\n<\/tr>\r\n
Wound irrigation<\/td>\r\nThe wound is irrigated each time the dressing is changed. See specific wound guidelines about volume used to irrigate. The volume of irrigation solution is dependent on the size of wound and amount of exudate. Usually \"irrigate until clear.\" The majority of irrigation fluid should be recovered. If not, stop and consult the prescriber or wound care specialist. Begin irrigation at one part of the wound and move methodically\u00a0 looking for tunnels whilst irrigating. Note the placement of the tunnel (using a clock face i.e. 12 o'clock) and note the depth of each tunnel.<\/td>\r\n<\/tr>\r\n
Irrigation pressure<\/td>\r\nThe pressure of irrigating must be strong enough to remove debris but not damage the new tissue. Generally, a 35 ml syringe with a 19 gauge blunt tip will provide sufficient PSI for irrigation.<\/td>\r\n<\/tr>\r\n
Wound assessment<\/td>\r\nWound assessment must be done with each dressing change to ensure the product is adequately meeting the needs of the wound.<\/td>\r\n<\/tr>\r\n
Swabbing the wound<\/td>\r\nSwab for culture, if required. Always swab a wound after irrigation. See agency protocols for how to obtain a wound C&S.<\/td>\r\n<\/tr>\r\n
Packing material<\/td>\r\nPacking material must be removed with each dressing change. Only one piece of gauze or dressing material should be used in wounds with sinus tracts or tunneling to avoid the risk of retaining dressing\/packing material. If there is a concern that packing is retained in the wound, contact the wound specialist or physician for follow-up.\r\n\r\nAlways leave a \"tail\" of the packing strip outside the wound. If more than one piece of packing is used, leave the tails outside the wound by securing the tails to the skin with a piece of Steri-Strip if needed.<\/td>\r\n<\/tr>\r\n
Documentation<\/td>\r\nWound assessment and dressing change must be documented each time. Each wound requires a separate wound care sheet. Type and quantity of packing material (length or pieces), along with the number of inner and outer dressings should be recorded as per agency policy.\u00a0For any cavity, undermining, sinus tract, or tunnel with a depth greater than 1 cm (> 1 cm), count and document the number of packing pieces removed from the wound, and the number of packing pieces inserted into the wound.<\/td>\r\n<\/tr>\r\n
Communication<\/td>\r\nA copy of the most recent wound care assessment and dressing change should be sent with patient upon transfer to another healthcare facility.<\/td>\r\n<\/tr>\r\n
Use of sterile gloves for packing<\/td>\r\nSterile gloves may be used if packing a large or complex wound.<\/td>\r\n<\/tr>\r\n
Data sources: British Columbia Provincial Nursing Skin and Wound Committee,\u00a02014; Harris, 2017; Saskatoon Health Region, 2013<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nThe healthcare professional chooses the method of cleansing (a squeezable sterile normal saline container or a 10 to 60 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.\r\n\r\nAgency policy will determine the wound cleansing solution, and\/or product to be used to impregnate the gauze to be packed into the wound. Generally sterile normal saline and sterile water are the solutions of choice. Warmed solutions may increase patient comfort (Harris et al., 2018)\r\n\r\nUndermining, sinuses, and tunnels can only be irrigated when there is a known endpoint.\u00a0Do not irrigate undermining, sinuses, or tunnels that extend beyond 15 cm unless directed\u00a0by a physician or nurse practitioner (NP).\u00a0If 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, physician, or NP.\r\n\r\nChecklist 37 outlines the steps for irrigating and packing a wound.\r\n
\r\n
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\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
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<\/a>Checklist 37: Wound Irrigation and Packing<\/h3>\r\n
Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n

\r\n
Safety considerations:<\/span><\/h5>\r\n
\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. Review order for wound care.<\/td>\r\nConfirm\u00a0that prescriber's orders are appropriate to wound assessment.<\/td>\r\n<\/tr>\r\n
2. Perform hand hygiene.<\/td>\r\nHand hygiene reduces the risk of infection.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]\"Hand<\/a> Hand hygiene with ABHR[\/caption]<\/td>\r\n<\/tr>\r\n
3. Gather necessary equipment and supplies:\r\n
    \r\n \t
  • Syringe (10 to 60 ml)<\/li>\r\n \t
  • Cannula with needleless adaptor (a.k.a. irrigation catheter)<\/li>\r\n \t
  • Irrigation fluid (usually saline)<\/li>\r\n \t
  • Basin<\/li>\r\n \t
  • Waterproof pad<\/li>\r\n \t
  • Dressing tray<\/li>\r\n \t
  • Scissors if wound packing materials must be cut<\/li>\r\n \t
  • Skin barrier \/ protectant<\/li>\r\n \t
  • Cotton tip applicators<\/li>\r\n \t
  • Measuring guide<\/li>\r\n \t
  • Outer sterile dressing<\/li>\r\n \t
  • Packing gauze or packing as per physician's orders<\/li>\r\n<\/ul>\r\nSome agencies provide a prepackaged sterile irrigation tray.<\/td>\r\n
Being organized will help with efficiency and expedite the procedure, minimizing the length of time the patient experiences discomfort.\r\n\r\n[caption id=\"attachment_5644\" align=\"aligncenter\" width=\"150\"]\"Gather<\/a> Gather supplies and set up sterile tray[\/caption]<\/td>\r\n<\/tr>\r\n
4. Position patient to allow solution to flow off patient.\r\n\r\nPosition patient so wound is vertical to the collection basin.<\/td>\r\n\r\n\r\n[caption id=\"attachment_5645\" align=\"aligncenter\" width=\"150\"]\"Position<\/a> Position patient on side[\/caption]<\/td>\r\n<\/tr>\r\n
5. Place\u00a0waterproof pad under patient.\r\n\r\nSet up sterile field and supplies.<\/td>\r\nProtect patient's clothing and bedding from irrigation fluid.<\/td>\r\n<\/tr>\r\n
6.\u00a0Remove outer dressing with non-sterile glove.\r\n\r\nUsing transfer forceps, remove inner dressing (packing) from the wound.\r\n\r\nIf the packing sticks, gently soak the packing with normal saline or sterile water and gently lift off the packing.\r\n\r\nConfirm the quantity and type of packing is the same as recorded on previous dressing change.<\/td>\r\n\r\n\r\n[caption id=\"attachment_5646\" align=\"aligncenter\" width=\"150\"]\"Remove<\/a> Remove outer dressing[\/caption]\r\n\r\nRemoving packing that adheres to the wound bed without soaking can cause trauma to the wound bed tissue.\r\n\r\nIf packing material cannot be removed, contact the physician, NP, or wound clinician.\r\n\r\nIf packing adheres to the wound, reassess the amount of wound exudate and consider a different packing material.\r\n\r\n[caption id=\"attachment_5649\" align=\"aligncenter\" width=\"150\"]\"Remove<\/a> Remove inner dressing[\/caption]\r\n\r\nAll packing must be removed with each dressing change.<\/td>\r\n<\/tr>\r\n
7.\u00a0Assess the wound.\r\n
    \r\n \t
  • Take measurements, including length, width, and depth.<\/li>\r\n \t
  • For undermining or tunneling, note location and size.<\/li>\r\n \t
  • Look for evidence of bone or tendon exposure.<\/li>\r\n \t
  • Assess\u00a0appearance of wound bed, noting percentage of tissue types.<\/li>\r\n \t
  • Note\u00a0presence of odor after cleansing.<\/li>\r\n \t
  • Assess\u00a0appearance of wound edge and peri-wound skin.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n\r\n[caption id=\"attachment_5651\" align=\"aligncenter\" width=\"150\"]\"Assess<\/a> Assess the wound[\/caption]\r\n\r\nWound assessment helps identify if the wound care is effective.\r\n\r\nAlways compare the current wound assessment with the previous assessment to determine if the wound is healing, delayed, worsening, or showing signs of infection.<\/td>\r\n<\/tr>\r\n
8. Apply non-sterile gloves, gown, and goggles or face shield according to your point of care risk assessment.<\/td>\r\nThe use of personal protective equipment<\/a> (PPE) reduces the risk of your exposure to BBF\r\n\r\n[caption id=\"attachment_5559\" align=\"aligncenter\" width=\"150\"]\"Apply<\/a> Apply non-sterile gloves[\/caption]<\/td>\r\n<\/tr>\r\n
9. Fill 35 to\u00a060 ml syringe with sterile water or irrigating solution, and attach an irrigation tip to the end of syringe.<\/td>\r\n\r\n\r\n[caption id=\"attachment_5652\" align=\"aligncenter\" width=\"150\"]\"Fill<\/a> Fill syringe with irrigating solution[\/caption]<\/td>\r\n<\/tr>\r\n
10. Hold the irrigation tip very close to the wound and flush wound using gently continuous pressure until returns run clear into the basin.\r\n\r\nIf irrigating a deep wound with a very small opening, attach an irrigation tip catheter to the syringe. Insert the tip searching for undermining and tunnels, measuring and noting the location and depth of each.\r\n\r\nUse slow continuous pressure to flush wound.\r\n\r\nRepeat flushing procedure until returns run clear into the basin. If the majority of the irrigation fluid is not recovered stop and consult the prescriber.<\/td>\r\n\r\n\r\n[caption id=\"attachment_5653\" align=\"aligncenter\" width=\"150\"]\"Irrigate<\/a> Irrigate wound[\/caption]\r\n\r\nIrrigation should be drained into basin. Retained irrigation fluid is a medium for bacterial growth and subsequent infection.\r\n\r\nIrrigation should not increase patient discomfort.\r\n\r\nThe irrigation tip controls the pressure of the fluid, not the force of the plunger.<\/td>\r\n<\/tr>\r\n
11. Clean and dry wound edges with sterile gauze using sterile forceps.<\/td>\r\n\r\n\r\n[caption id=\"attachment_5654\" align=\"aligncenter\" width=\"150\"]\"Dry<\/a> Clean & dry wound edges with sterile gauze[\/caption]\r\n\r\nThis step prevents maceration of surrounding tissue from excess moisture.<\/td>\r\n<\/tr>\r\n
12. Remove goggles or face shield.<\/td>\r\n<\/td>\r\n<\/tr>\r\n
13. Perform hand hygiene and apply sterile gloves (if not using sterile forceps) or non-sterile gloves.<\/td>\r\nHand hygiene reduces the risk of infection.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]\"Hand<\/a> Hand hygiene with ABHR[\/caption]<\/td>\r\n<\/tr>\r\n
14.\u00a0For normal saline gauze packing:\r\n
    \r\n \t
  • Moisten the gauze with sterile normal saline, and wring it out so it is damp but not wet.<\/li>\r\n \t
  • Enclose any non-woven edges in the centre of the packing material to reduce the risk of loose threads in the wound.<\/li>\r\n<\/ul>\r\nFor other packing materials (e.g., hydrogel, iodine [povidone & cadexomer],\u00a0PHMB), see the specific product information.\r\n\r\n <\/td>\r\n
The wound must be moist, not wet, for optimal healing.\u00a0Gauze packing that is too wet can cause tissue maceration, and it reduces the absorbency of the gauze.\r\n\r\n[caption id=\"attachment_5655\" align=\"aligncenter\" width=\"150\"]\"Moisten<\/a> Moisten gauze[\/caption]\r\n\r\nIf using normal saline gauze packing, it needs to be changed often throughout the day to prevent the gauze from drying out.\r\n\r\nIf it is necessary to use more than one ribbon packing piece, the pieces must be tied together using sterile gloves; ensure the knot(s) is secure.<\/td>\r\n<\/tr>\r\n
15. Open gauze and gently pack it into wound using either forceps, the tip of a cotton swab stick, or sterile gloved hands. Begin with the deepest part of the wound and finish at the surface.\r\n\r\nEnsure the wound is not over-packed or under-packed as this may diminish the healing process.\r\n\r\nApply skin protectant to peri-wound skin.<\/td>\r\nContinue to pack the wound until all<\/em> wound surfaces are in contact with gauze.\r\n\r\n[caption id=\"attachment_5658\" align=\"aligncenter\" width=\"150\"]\"Apply<\/a> Apply packing to wound[\/caption]\r\n\r\nKeep the moist dressing off of the peri-wound skin.\r\n\r\n\u200bSaturated packing materials and\/or wound exudate may macerate or irritate unprotected peri-wound skin.<\/td>\r\n<\/tr>\r\n
16.\u00a0Always leave a \u201ctail\u201d of packing materials either clearly visible in the wound cavity or on the peri-wound skin.\r\n\r\nUse a Steri-Strip to secure the packing tail to the peri-wound skin.\r\n\r\nIf two or more packing pieces have been knotted together, ensure that the knots are placed in the wound cavity, not in the undermining, sinus tract, or tunnel.<\/td>\r\n\r\n\r\n[caption id=\"attachment_6388\" align=\"aligncenter\" width=\"150\"]\"leave<\/a> Leave a \u201ctail\u201d of packing materials[\/caption]\r\n\r\nIf the knot is visible in the wound, it is less likely that a packing piece will be lost if the knot comes undone.\r\n\r\nA knot exerting pressure on the wound surface may impair blood flow and potentially cause necrosis in the wound.<\/td>\r\n<\/tr>\r\n
17. Apply an appropriate outer dry\u00a0dressing, depending on the frequency of the dressing changes and the amount of exudate from the wound. Secure the dressing.<\/td>\r\nThe dressing on the wound must remain dry on the outside until the next dressing change to reduce risk of introducing more microorganisms into the wound.\r\n\r\n[caption id=\"attachment_5662\" align=\"aligncenter\" width=\"150\"]\"Apply<\/a> Apply outer dressing[\/caption]<\/td>\r\n<\/tr>\r\n
18. Discard supplies and perform hand hygiene.<\/td>\r\nThis prevents the transfer of microorganisms.\r\n\r\n[caption id=\"attachment_5940\" align=\"aligncenter\" width=\"150\"]\"Perform<\/a> Perform hand hygiene[\/caption]<\/td>\r\n<\/tr>\r\n
19. Help patient back into a comfortable position, and lower the bed.<\/td>\r\nThis step optimizes patient safety.<\/td>\r\n<\/tr>\r\n
20. Document wound assessment, irrigation solution, dressings used for packing, and patient response to the procedure.\r\n\r\nDocumentation should include date and time of procedure.\r\n\r\nReport any unusual findings or concerns to the appropriate healthcare professional.<\/td>\r\nThis allows for effective communication between healthcare providers.\r\n\r\nNotify required healthcare providers if wound appears infected or is not healing as expected.\r\n\r\nSample charting: date \/ time. Abdominal\u00a0wound dressing changed. Large amount foul smelling purulent drainage present. wound irrigated with 60 ml NS using irrigation tip catheter and syringe. 2 cm tunnel at 12 o'clock and 4 cm tunnel at 5 o'clock. Wound bed approx 1.5 cm \u00d7 2 cm \u00d7 0.5 cm. Wound bed 50 % red 50% yellow slough. Tunnels and wound bed packed with hydrogel soaked ribbon gauze\u00a0approx 20 cm in total. Peri-wound skin macerated extending approx. 3 cm. Skin prep applied to same. Covered with ABD pad. Tolerated with some voiced discomfort.-----------------------YIkes RN<\/em><\/td>\r\n<\/tr>\r\n
Data sources: BCIT, 2010b; Perry et al., 2018<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
Watch the video Wound Irrigation and Packing <\/em><\/a>by Ren\u00e9e Anderson and Wendy McKenzie Thompson Rivers University.<\/div>\r\nThe following links provide additional information about wound packing and wound measuring.\r\n
Read\u00a0British Columbia Provincial Nursing Skin & Wound Committee's\u00a0Procedure: Wound Packing<\/em><\/a>\u00a0(2017) to learn more about\u00a0wound packing procedure.<\/div>\r\n
Take Vancouver Coastal Health Authority's\u00a0Wound Assessment<\/em><\/a> course (2009) to learn more about wound measuring and assessment.<\/div>\r\n
\r\n
\r\n
\r\n
\r\n

Critical Thinking Exercises<\/h3>\r\n
    \r\n \t
  1. Provide a rationale for selecting PPE when performing wound irrigation (eye protection; gown; non-sterile gloves; sterile gloves).<\/li>\r\n \t
  2. Which elements are important to consider when assessing a closed surgical incision?<\/li>\r\n \t
  3. What elements are important to consider when assessing an open wound?<\/li>\r\n<\/ol>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>","rendered":"

    Traditionally, when wounds required debridement wet to dry dressings were used. This involved applying moist saline or other solution (i.e., Dakin’s) to gauze, placing it into a wound bed, allowing it to dry, and then removing it. As the dressing is removed, so is the unhealthy tissue. The belief was that the removal of the dead tissue facilitated healing. As we have come to understand more about wound healing, we now know that this practice disrupts healthy tissue. Besides being detrimental to wound healing, it can also be painful for the patient. As such, this is not current best practice (Kerr et al., 2014).<\/p>\n

    We have come to understand that wound beds need a moist environment to heal. Wet to moist dressings provide a moist healing environment, but they can require several dressing changes each day to maintain that moisture. These frequent dressing changes come with personal cost to the patient, financial cost in terms of nursing time and supplies, risk of infection associated with frequent dressing changes, and potential damage to the wound bed if the dressing is allowed to dry out (Kerr et al., 2014).<\/p>\n

    A wet to moist dressing can be selected for a wound bed until further direction is given by someone with knowledge about wound products. The type of wound dressing used depends not only on the characteristics of the wound, but also on the goal of the wound treatment and ability to access products. Recalling factors that influence wound healing, the skill and knowledge of the healthcare professional (HCP) and their ability to diagnose, select appropriate treatments, and correctly implement treatments are important considerations in relation to wound care\u00a0 (Norton et al., 2018; Harris et al., 2018).<\/p>\n

    Wet to Moist Dressing<\/h2>\n

    A\u00a0wet to moist dressing involves a primary dressing that directly touches the wound bed, and a secondary dressing covering it.<\/p>\n

    Important<\/strong>: Ensure pain is well managed prior to a dressing change to maximize patient comfort.<\/p>\n

    Checklist 36 outlines the steps for performing a wet to moist dressing change.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
    \n

    <\/a>Checklist 36: Wet to Moist Dressing Change<\/h3>\n
    Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n

    \n
    Safety considerations:<\/span><\/h5>\n
    \n

    Steps<\/h4>\n<\/td>\n

    		\n

    \u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    1. Check present dressing using\u00a0non-sterile gloves if necessary.<\/td>\nThis provides an opportunity for assessment and to determine required supplies for the procedure.<\/td>\n<\/tr>\n
    2. Perform hand hygiene.<\/td>\nHand hygiene reduces the risk of infection.<\/p>\n
    \"Perform<\/a>
    Perform hand hygiene<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    3. Gather necessary equipment and supplies.<\/td>\nBeing organized will help with efficiency and expedite the procedure, minimizing the length of time the patient experiences discomfort.<\/td>\n<\/tr>\n
    4. Prepare environment; position patient; adjust height of bed; turn on lights; and sanitize working surface.<\/td>\nThis helps prepare patient and bedside for procedure.<\/td>\n<\/tr>\n
    5. Perform hand hygiene.<\/td>\nHand hygiene reduces the risk of infection.<\/p>\n
    \"Hand<\/a>
    Hand hygiene with ABHR<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    6. Decide if this is a clean or sterile procedure. If a clean procedure, use non-sterile gloves. If a sterile procedure, use sterile gloves and follow principles of asepsis.<\/p>\n

    Prepare field.<\/td>\n

    		\n
    \"Sterile<\/a>
    Sterile field<\/figcaption><\/figure>\n

    Whether this is a sterile or clean procedure, always reduce risk of transmitting microorganisms to patients<\/td>\n<\/tr>\n

    7. Add necessary sterile supplies. If this is a sterile procedure, use sterile saline.<\/p>\n

    If you are irrigating the wound, you will need irrigation equipment (10 ml syringe and wound irrigation catheter).<\/td>\n

    		\n
    \"Adding<\/a>
    Add supplies<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    8. Pour cleansing solution into two separate compartments.<\/p>\n

    Place gauze and saline to be used for wound packing in its own compartment.<\/td>\n

    		\n
    \"Pouring<\/a>
    Pour cleansing solution<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    9. Apply non-sterile gloves.<\/td>\nThis reduces the risk of contaminating your\u00a0hands with the patient’s blood and other body fluids.<\/p>\n

    It also\u00a0reduces the risk of germ transmission from you to the patient and vice versa, as well as from one patient to another.<\/p>\n

    \"Apply<\/a>
    Apply non-sterile gloves<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    10.\u00a0Remove outer dressing with non-sterile gloves.<\/td>\n\n
    \"Removing<\/a>
    Remove outer dressing with non-sterile gloves<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    11.\u00a0Remove inner dressing with transfer forceps, and assess the old dressing and the wound.<\/td>\n\n
    \"Remove<\/a>
    Remove inner dressing with forceps<\/figcaption><\/figure>\n

    Inspect wound\u00a0for evidence of healing or complications including the amount and type of drainage, odor, presence of staples \/ sutures, wound approximation, peri skin condition.<\/td>\n<\/tr>\n

    12.\u00a0Discard transfer forceps and non-sterile gloves.<\/td>\n\n
    \"Discard<\/a>
    Discard transfer forceps<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    13. Drape patient with underpad (optional).<\/td>\n\n
    \"Drape<\/a>
    Drape patient with underpad<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    14. Clean the peri-wound skin and clean the wound bed either by irrigating or with sterile gauze and saline.<\/td>\nIrrigating with 10 pounds per square inch (PSI) and\/or wiping gently with sterile gauze helps to lift slough and clean the wound bed.<\/td>\n<\/tr>\n
    15. Apply sterile or clean gloves (depending if the nature of the wound calls for a clean or sterile procedure).<\/p>\n

    Wring-out excess solution from the gauze to be used for packing.<\/p>\n

    “Not too wet and and not too dry … just like your eye” (author unknown)<\/td>\n

    		Use enough saline to saturate gauze. Too much moisture can cause the peri-wound skin to become macerated.<\/p>\n
    \"Saturate<\/a>
    Saturate gauze<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    16. Fluff up the moist gauze. Place into wound ensuring the wound bed is in contact with the moisture. Ensure gauze does\u00a0not touch peri-wound skin.<\/td>\nApply skin preparation to peri-wound skin if there is risk of skin breakdown.<\/p>\n

     <\/td>\n<\/tr>\n

    17. Apply cover dressing. Secure with tape, stockinette, or\u00a0 kling.<\/td>\nSelect a cover dressing that will help the gauze to remain moist until the next dressing change (i.e., one that won’t wick away all of the moisture and cause the gauze to dry out).<\/td>\n<\/tr>\n
    18. Discard gloves according to agency policy, and\u00a0perform hand hygiene.<\/td>\nHand hygiene reduces the risk of infection.<\/p>\n
    \"Book<\/a>
    Discard gloves<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    19. Next:<\/p>\n
      \n
    • Assist patient to comfortable position.<\/li>\n
    • Lower patient\u2019s bed.<\/li>\n
    • Discard used equipment appropriately.<\/li>\n<\/ul>\n<\/td>\n
    		These steps ensure the patient’s continued safety.<\/td>\n<\/tr>\n
    20. Document procedure and\u00a0findings according to agency policy.<\/p>\n

    Report any unusual findings or concerns to the appropriate healthcare professional.<\/td>\n

    		Record dressing change:\u00a0time, place of wound, wound characteristics, presence of staples or sutures, size, drainage type and amount, type of cleansing solution and dressing applied.<\/p>\n

     <\/p>\n

    Sample charting:<\/p>\n

    date \/ time.\u00a0Right\u00a0lateral ankle dressing changed. Large amount\u00a0of sero purulent drainage. No odor. Wound approx 2 cm \u00d7 3 cm \u00d7 0.5 cm. Wound bed 90 % yellow slough 10% red. Irrigated with 30 ml normal saline. Packed with 4\u00d74 gauze moist with saline. Covered with ABD pad and secured with stockinette. Peri-wound skin intact. Tolerated well.\u00a0 —————T Rex RN<\/em><\/td>\n<\/tr>\n

    Data sources:\u00a0Perry et al., 2018;\u00a0WHO, 2009<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    Wound Irrigation and Packing<\/h2>\n

    Wound irrigation and packing refer to\u00a0the 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, 2017).<\/p>\n

    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\u00a0from 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 healthcare professional and according to agency guidelines.<\/p>\n

    Contraindications to packing a wound include a fistula\u00a0tract,\u00a0a wound with an unknown endpoint to tunneling, 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).<\/p>\n

    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).<\/p>\n

    The 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 gauze impregnated with polyhexaamethylene biguanide (PHMB), iodine (povidone and cadexomer), ribbon dressing, hydro-fiber dressing, alginate antimicrobial dressing, and a negative pressure foam or gauze dressing. Table 4.7 lists some wound care products and indications for each. 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,\u00a02014).<\/p>\n

    Additional guidelines to irrigating and packing a wound are listed in Table 4.8.<\/p>\n

    Wound Care Products<\/h2>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
    \n

    Table 4.7 Wound Care Products<\/h3>\n<\/td>\n<\/tr>\n

    \n

    Type<\/h4>\n<\/td>\n

    		\n

    Indications<\/h4>\n<\/td>\n<\/tr>\n

    Non-adherent contact layer (i.e., Telfa, silicone, petroleum-based woven dressings)<\/td>\nAllows the wound to drain with minimal disruption to the wound bed when the dressing is removed. Requires an outer dressing.<\/td>\n<\/tr>\n
    Hydrocolloid<\/td>\n\n
      \n
    • Minimal absorption capability (not for highly draining wounds)<\/li>\n
    • Good for autolytic debridement<\/li>\n
    • Maintains moist wound bed<\/li>\n
    • Impermeable to external contamination<\/li>\n
    • Self-adhesive and pliable, so conforms to the body<\/li>\n
    • Duration approx. 5 to 7 days<\/li>\n
    • All gel must be removed between dressing changes<\/li>\n
    • Not for infected or necrotic wounds<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Hydrogel<\/td>\n\n
      \n
    • Introduces moisture into the wound<\/li>\n
    • Absorbs small amounts of exudate<\/li>\n
    • Debrides wound by softening necrotic tissue<\/li>\n
    • Does not adhere to wound base<\/li>\n
    • Duration approx. 5 to 7 days<\/li>\n
    • All gel must be removed between dressing changes<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Calcium alginates<\/td>\n\n
      \n
    • Manufactured from seaweed<\/li>\n
    • Highly absorbent<\/li>\n
    • Becomes a gel in presence of moisture<\/li>\n
    • Available as sheet or rope form<\/li>\n
    • Requires an outer dressing<\/li>\n
    • Must be fitted to the wound bed and not in contact with peri-wound skin<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Foams<\/td>\n\n
      \n
    • Used for highly draining wounds<\/li>\n
    • Autolytic debridement<\/li>\n
    • Change frequency depends on wound drainage (1 to 3 days)<\/li>\n
    • Not for infected wounds<\/li>\n
    • Not for dry necrosis<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Charcoal<\/td>\n\n
      \n
    • Charcoal imbedded in product and is odour absorbent<\/li>\n
    • Requires an outer dressing<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Anti-microbials<\/td>\n\n
      \n
    • Medical grade honey, silver, cadexomer iodine, alginates, foams, pastes<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Negative Pressure Wound Therapy (NPWT)<\/td>\n\n
      \n
    • Also knows as VAC dressing, vacuum assisted closure<\/li>\n
    • Manages large amounts of exudate<\/li>\n
    • Sub-atmospheric pressure applied to a wound bed promotes and accelerates healing<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    BHMB<\/td>\n\n
      \n
    • Antimicrobial \/ antiseptic impregnated into guaze (strips or sheets) and foam dressings<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Silver impregnated gauze \/ foams<\/td>\n\n
      \n
    • \u00a0Silver is antimicrobial and promotes healing. Foam absorbs moisture<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Combination products<\/td>\n\n
      \n
    • Can include more than one of the above (e.g., silver and charcoal)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Data sources: Alavi et al., 2015; Eberlein & Assadian, 2010; Kerr et al., 2014; Munteanu et al, 2016; Wiegand et al., 2015<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
    \n

    Table 4.8 General Guidelines for Irrigating and Packing a Complicated Wound<\/h3>\n<\/td>\n<\/tr>\n

    \n

    Guideline<\/h4>\n<\/td>\n

    		\n

    \u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    Aseptic technique<\/td>\nSterile technique or no-touch technique may be used for irrigating and packing a wound. The use of a specific technique is based on agency policy, condition of the client, heal-ability of the wound, invasiveness, and goal of the wound care. Sterile technique or no-touch technique must be used in all acute care settings. Clean technique may be used for chronic wounds in long-term-care and home settings.<\/td>\n<\/tr>\n
    Type of solution for irrigation<\/td>\nThe most common solution used is normal saline at room temperature, unless otherwise ordered. Check prescriber’s \/ wound care specialist’s orders.<\/p>\n

    Non-potable water should never be used for cleansing of post operative wounds. Boiled and cooled water is an acceptable alternative (Johanna Briggs Institute, 2006, as cited in Harris et al., 2018)<\/td>\n<\/tr>\n

    Wound irrigation<\/td>\nThe wound is irrigated each time the dressing is changed. See specific wound guidelines about volume used to irrigate. The volume of irrigation solution is dependent on the size of wound and amount of exudate. Usually “irrigate until clear.” The majority of irrigation fluid should be recovered. If not, stop and consult the prescriber or wound care specialist. Begin irrigation at one part of the wound and move methodically\u00a0 looking for tunnels whilst irrigating. Note the placement of the tunnel (using a clock face i.e. 12 o’clock) and note the depth of each tunnel.<\/td>\n<\/tr>\n
    Irrigation pressure<\/td>\nThe pressure of irrigating must be strong enough to remove debris but not damage the new tissue. Generally, a 35 ml syringe with a 19 gauge blunt tip will provide sufficient PSI for irrigation.<\/td>\n<\/tr>\n
    Wound assessment<\/td>\nWound assessment must be done with each dressing change to ensure the product is adequately meeting the needs of the wound.<\/td>\n<\/tr>\n
    Swabbing the wound<\/td>\nSwab for culture, if required. Always swab a wound after irrigation. See agency protocols for how to obtain a wound C&S.<\/td>\n<\/tr>\n
    Packing material<\/td>\nPacking material must be removed with each dressing change. Only one piece of gauze or dressing material should be used in wounds with sinus tracts or tunneling to avoid the risk of retaining dressing\/packing material. If there is a concern that packing is retained in the wound, contact the wound specialist or physician for follow-up.<\/p>\n

    Always leave a “tail” of the packing strip outside the wound. If more than one piece of packing is used, leave the tails outside the wound by securing the tails to the skin with a piece of Steri-Strip if needed.<\/td>\n<\/tr>\n

    Documentation<\/td>\nWound assessment and dressing change must be documented each time. Each wound requires a separate wound care sheet. Type and quantity of packing material (length or pieces), along with the number of inner and outer dressings should be recorded as per agency policy.\u00a0For any cavity, undermining, sinus tract, or tunnel with a depth greater than 1 cm (> 1 cm), count and document the number of packing pieces removed from the wound, and the number of packing pieces inserted into the wound.<\/td>\n<\/tr>\n
    Communication<\/td>\nA copy of the most recent wound care assessment and dressing change should be sent with patient upon transfer to another healthcare facility.<\/td>\n<\/tr>\n
    Use of sterile gloves for packing<\/td>\nSterile gloves may be used if packing a large or complex wound.<\/td>\n<\/tr>\n
    Data sources: British Columbia Provincial Nursing Skin and Wound Committee,\u00a02014; Harris, 2017; Saskatoon Health Region, 2013<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    The healthcare professional chooses the method of cleansing (a squeezable sterile normal saline container or a 10 to 60 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.<\/p>\n

    Agency policy will determine the wound cleansing solution, and\/or product to be used to impregnate the gauze to be packed into the wound. Generally sterile normal saline and sterile water are the solutions of choice. Warmed solutions may increase patient comfort (Harris et al., 2018)<\/p>\n

    Undermining, sinuses, and tunnels can only be irrigated when there is a known endpoint.\u00a0Do not irrigate undermining, sinuses, or tunnels that extend beyond 15 cm unless directed\u00a0by a physician or nurse practitioner (NP).\u00a0If 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, physician, or NP.<\/p>\n

    Checklist 37 outlines the steps for irrigating and packing a wound.<\/p>\n

    \n
    \n
    \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
    \n

    <\/a>Checklist 37: Wound Irrigation and Packing<\/h3>\n
    Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n

    \n
    Safety considerations:<\/span><\/h5>\n
    \n

    Steps<\/h4>\n<\/td>\n

    		\n

    \u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    1. Review order for wound care.<\/td>\nConfirm\u00a0that prescriber’s orders are appropriate to wound assessment.<\/td>\n<\/tr>\n
    2. Perform hand hygiene.<\/td>\nHand hygiene reduces the risk of infection.<\/p>\n
    \"Hand<\/a>
    Hand hygiene with ABHR<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    3. Gather necessary equipment and supplies:<\/p>\n
      \n
    • Syringe (10 to 60 ml)<\/li>\n
    • Cannula with needleless adaptor (a.k.a. irrigation catheter)<\/li>\n
    • Irrigation fluid (usually saline)<\/li>\n
    • Basin<\/li>\n
    • Waterproof pad<\/li>\n
    • Dressing tray<\/li>\n
    • Scissors if wound packing materials must be cut<\/li>\n
    • Skin barrier \/ protectant<\/li>\n
    • Cotton tip applicators<\/li>\n
    • Measuring guide<\/li>\n
    • Outer sterile dressing<\/li>\n
    • Packing gauze or packing as per physician’s orders<\/li>\n<\/ul>\n

      Some agencies provide a prepackaged sterile irrigation tray.<\/td>\n

    		Being organized will help with efficiency and expedite the procedure, minimizing the length of time the patient experiences discomfort.<\/p>\n
    \"Gather<\/a>
    Gather supplies and set up sterile tray<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    4. Position patient to allow solution to flow off patient.<\/p>\n

    Position patient so wound is vertical to the collection basin.<\/td>\n

    		\n
    \"Position<\/a>
    Position patient on side<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    5. Place\u00a0waterproof pad under patient.<\/p>\n

    Set up sterile field and supplies.<\/td>\n

    		Protect patient’s clothing and bedding from irrigation fluid.<\/td>\n<\/tr>\n
    6.\u00a0Remove outer dressing with non-sterile glove.<\/p>\n

    Using transfer forceps, remove inner dressing (packing) from the wound.<\/p>\n

    If the packing sticks, gently soak the packing with normal saline or sterile water and gently lift off the packing.<\/p>\n

    Confirm the quantity and type of packing is the same as recorded on previous dressing change.<\/td>\n

    		\n
    \"Remove<\/a>
    Remove outer dressing<\/figcaption><\/figure>\n

    Removing packing that adheres to the wound bed without soaking can cause trauma to the wound bed tissue.<\/p>\n

    If packing material cannot be removed, contact the physician, NP, or wound clinician.<\/p>\n

    If packing adheres to the wound, reassess the amount of wound exudate and consider a different packing material.<\/p>\n

    \"Remove<\/a>
    Remove inner dressing<\/figcaption><\/figure>\n

    All packing must be removed with each dressing change.<\/td>\n<\/tr>\n

    7.\u00a0Assess the wound.<\/p>\n
      \n
    • Take measurements, including length, width, and depth.<\/li>\n
    • For undermining or tunneling, note location and size.<\/li>\n
    • Look for evidence of bone or tendon exposure.<\/li>\n
    • Assess\u00a0appearance of wound bed, noting percentage of tissue types.<\/li>\n
    • Note\u00a0presence of odor after cleansing.<\/li>\n
    • Assess\u00a0appearance of wound edge and peri-wound skin.<\/li>\n<\/ul>\n<\/td>\n
    		\n
    \"Assess<\/a>
    Assess the wound<\/figcaption><\/figure>\n

    Wound assessment helps identify if the wound care is effective.<\/p>\n

    Always compare the current wound assessment with the previous assessment to determine if the wound is healing, delayed, worsening, or showing signs of infection.<\/td>\n<\/tr>\n

    8. Apply non-sterile gloves, gown, and goggles or face shield according to your point of care risk assessment.<\/td>\nThe use of personal protective equipment<\/a> (PPE) reduces the risk of your exposure to BBF<\/p>\n
    \"Apply<\/a>
    Apply non-sterile gloves<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    9. Fill 35 to\u00a060 ml syringe with sterile water or irrigating solution, and attach an irrigation tip to the end of syringe.<\/td>\n\n
    \"Fill<\/a>
    Fill syringe with irrigating solution<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    10. Hold the irrigation tip very close to the wound and flush wound using gently continuous pressure until returns run clear into the basin.<\/p>\n

    If irrigating a deep wound with a very small opening, attach an irrigation tip catheter to the syringe. Insert the tip searching for undermining and tunnels, measuring and noting the location and depth of each.<\/p>\n

    Use slow continuous pressure to flush wound.<\/p>\n

    Repeat flushing procedure until returns run clear into the basin. If the majority of the irrigation fluid is not recovered stop and consult the prescriber.<\/td>\n

    		\n
    \"Irrigate<\/a>
    Irrigate wound<\/figcaption><\/figure>\n

    Irrigation should be drained into basin. Retained irrigation fluid is a medium for bacterial growth and subsequent infection.<\/p>\n

    Irrigation should not increase patient discomfort.<\/p>\n

    The irrigation tip controls the pressure of the fluid, not the force of the plunger.<\/td>\n<\/tr>\n

    11. Clean and dry wound edges with sterile gauze using sterile forceps.<\/td>\n\n
    \"Dry<\/a>
    Clean & dry wound edges with sterile gauze<\/figcaption><\/figure>\n

    This step prevents maceration of surrounding tissue from excess moisture.<\/td>\n<\/tr>\n

    12. Remove goggles or face shield.<\/td>\n<\/td>\n<\/tr>\n
    13. Perform hand hygiene and apply sterile gloves (if not using sterile forceps) or non-sterile gloves.<\/td>\nHand hygiene reduces the risk of infection.<\/p>\n
    \"Hand<\/a>
    Hand hygiene with ABHR<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    14.\u00a0For normal saline gauze packing:<\/p>\n
      \n
    • Moisten the gauze with sterile normal saline, and wring it out so it is damp but not wet.<\/li>\n
    • Enclose any non-woven edges in the centre of the packing material to reduce the risk of loose threads in the wound.<\/li>\n<\/ul>\n

      For other packing materials (e.g., hydrogel, iodine [povidone & cadexomer],\u00a0PHMB), see the specific product information.<\/p>\n

       <\/td>\n

    		The wound must be moist, not wet, for optimal healing.\u00a0Gauze packing that is too wet can cause tissue maceration, and it reduces the absorbency of the gauze.<\/p>\n
    \"Moisten<\/a>
    Moisten gauze<\/figcaption><\/figure>\n

    If using normal saline gauze packing, it needs to be changed often throughout the day to prevent the gauze from drying out.<\/p>\n

    If it is necessary to use more than one ribbon packing piece, the pieces must be tied together using sterile gloves; ensure the knot(s) is secure.<\/td>\n<\/tr>\n

    15. Open gauze and gently pack it into wound using either forceps, the tip of a cotton swab stick, or sterile gloved hands. Begin with the deepest part of the wound and finish at the surface.<\/p>\n

    Ensure the wound is not over-packed or under-packed as this may diminish the healing process.<\/p>\n

    Apply skin protectant to peri-wound skin.<\/td>\n

    		Continue to pack the wound until all<\/em> wound surfaces are in contact with gauze.<\/p>\n
    \"Apply<\/a>
    Apply packing to wound<\/figcaption><\/figure>\n

    Keep the moist dressing off of the peri-wound skin.<\/p>\n

    \u200bSaturated packing materials and\/or wound exudate may macerate or irritate unprotected peri-wound skin.<\/td>\n<\/tr>\n

    16.\u00a0Always leave a \u201ctail\u201d of packing materials either clearly visible in the wound cavity or on the peri-wound skin.<\/p>\n

    Use a Steri-Strip to secure the packing tail to the peri-wound skin.<\/p>\n

    If two or more packing pieces have been knotted together, ensure that the knots are placed in the wound cavity, not in the undermining, sinus tract, or tunnel.<\/td>\n

    		\n
    \"leave<\/a>
    Leave a \u201ctail\u201d of packing materials<\/figcaption><\/figure>\n

    If the knot is visible in the wound, it is less likely that a packing piece will be lost if the knot comes undone.<\/p>\n

    A knot exerting pressure on the wound surface may impair blood flow and potentially cause necrosis in the wound.<\/td>\n<\/tr>\n

    17. Apply an appropriate outer dry\u00a0dressing, depending on the frequency of the dressing changes and the amount of exudate from the wound. Secure the dressing.<\/td>\nThe dressing on the wound must remain dry on the outside until the next dressing change to reduce risk of introducing more microorganisms into the wound.<\/p>\n
    \"Apply<\/a>
    Apply outer dressing<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    18. Discard supplies and perform hand hygiene.<\/td>\nThis prevents the transfer of microorganisms.<\/p>\n
    \"Perform<\/a>
    Perform hand hygiene<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    19. Help patient back into a comfortable position, and lower the bed.<\/td>\nThis step optimizes patient safety.<\/td>\n<\/tr>\n
    20. Document wound assessment, irrigation solution, dressings used for packing, and patient response to the procedure.<\/p>\n

    Documentation should include date and time of procedure.<\/p>\n

    Report any unusual findings or concerns to the appropriate healthcare professional.<\/td>\n

    		This allows for effective communication between healthcare providers.<\/p>\n

    Notify required healthcare providers if wound appears infected or is not healing as expected.<\/p>\n

    Sample charting: date \/ time. Abdominal\u00a0wound dressing changed. Large amount foul smelling purulent drainage present. wound irrigated with 60 ml NS using irrigation tip catheter and syringe. 2 cm tunnel at 12 o’clock and 4 cm tunnel at 5 o’clock. Wound bed approx 1.5 cm \u00d7 2 cm \u00d7 0.5 cm. Wound bed 50 % red 50% yellow slough. Tunnels and wound bed packed with hydrogel soaked ribbon gauze\u00a0approx 20 cm in total. Peri-wound skin macerated extending approx. 3 cm. Skin prep applied to same. Covered with ABD pad. Tolerated with some voiced discomfort.———————–YIkes RN<\/em><\/td>\n<\/tr>\n

    Data sources: BCIT, 2010b; Perry et al., 2018<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
    Watch the video Wound Irrigation and Packing <\/em><\/a>by Ren\u00e9e Anderson and Wendy McKenzie Thompson Rivers University.<\/div>\n

    The following links provide additional information about wound packing and wound measuring.<\/p>\n

    Read\u00a0British Columbia Provincial Nursing Skin & Wound Committee’s\u00a0Procedure: Wound Packing<\/em><\/a>\u00a0(2017) to learn more about\u00a0wound packing procedure.<\/div>\n
    Take Vancouver Coastal Health Authority’s\u00a0Wound Assessment<\/em><\/a> course (2009) to learn more about wound measuring and assessment.<\/div>\n
    \n
    \n
    \n
    \n

    Critical Thinking Exercises<\/h3>\n
      \n
    1. Provide a rationale for selecting PPE when performing wound irrigation (eye protection; gown; non-sterile gloves; sterile gloves).<\/li>\n
    2. Which elements are important to consider when assessing a closed surgical incision?<\/li>\n
    3. What elements are important to consider when assessing an open wound?<\/li>\n<\/ol>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"author":397,"menu_order":6,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-571","chapter","type-chapter","status-publish","hentry"],"part":195,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/571","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/users\/397"}],"version-history":[{"count":26,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/571\/revisions"}],"predecessor-version":[{"id":5124,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/571\/revisions\/5124"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/parts\/195"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/571\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/media?parent=571"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapter-type?post=571"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/contributor?post=571"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/license?post=571"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}