Wound Cleansing & Wound Irrigation Diane L. Krasner PhD, RN, FAAN & Lia van Rijswijk DNP, RN, CWCN   Module #9 Revised September 2018

Disclaimer The Why Wound Care? education and recruitment campaign has been developed by our all-volunteer nursing and medical advisory boards. Website, logistics, marketing and exhibition support is provided by HMP with help from unrestricted educational grants from our corporate sponsors. A list of corporate sponsors can be found in the “About” tab. All educational materials were developed and are donated by our advisory board members. Neither HMP nor our corporate sponsors were involved in the selection, development, or content of these educational materials. Conflict of Interest: Dr. Diane Krasner and Dr. Lia van Rijswijk declare that they have no potential conflict of interest related to the content of this presentation.

Objectives To discuss the rationale for cleansing wounds To describe the underlying principles for irrigating wounds To describe methods and solutions for wound cleansing and wound irrigation

Wound Cleansing & Wound Irrigation Purpose Removal from the wound bed of - Proinflammatory material (e.g. devitalized tissue, bacteria) - Foreign bodies © Diane L. Krasner Used with permission Rodeheaver GT, Ratliff CR. Wound cleansing, wound irrigation, wound disinfection. In Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, Pa: HMP Communications, 2014:47-62. Downloadable at www.whywoundcare.com

Wound Cleansing & Wound Irrigation Principles The force of fluid application and type of solution used is based on the condition of the wound bed (assessment). Balance need for debris removal with need to prevent damage to healthy granulation tissue. Gentle flushing (e.g., pouring fluid from bottle) is usually sufficient for clean wounds with low levels of exudate.

Wound Cleansing The use of fluids to gently remove loosely adherent contaminants and devitalized material from the wound surface Sterile or non-sterile solutions may be used Not debridement May require some force (syringe) Rodeheaver GT, Ratliff CR. Wound cleansing, wound irrigation, wound disinfection. In Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, Pa: HMP Communications, 2014:47-62. Downloadable at www.whywoundcare.com

Wound Irrigation The use of hydraulic forces - generated by the stream of fluid – to loosen wound surface debris and flush it from the wound Devices used for wound irrigation include syringes and pulsed lavage. Pressures are measured in psi (pounds per square inch) Most commonly used pressure: 4 – 15 psi 35 ml syringe and 19 G angiocath or 100 ml. single use squeeze bottle = 7-8 psi Rodeheaver GT, Ratliff CR. Wound cleansing, wound irrigation, wound disinfection. In Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, Pa: HMP Communications, 2014:47-62. Downloadable at www.whywoundcare.com

Caution: Avoid traumatizing the wound (mechanical or chemical) during wound cleansing & wound irrigation Mechanical trauma includes using fluids that are cold (body temperature fluids are also less painful!) Avoid cytotoxic cleansing agents (such as antiseptics). They can damage healthy cells.

Usual Cleansing Solutions include: Normal saline solution pH balanced wound cleansers Note: Do not confuse wound cleansers with skin / incontinence cleansers! Tap water (from a safe water source)

The Evidence No differences have been noted in the rates of infection and healing between the use of tap water and sterile normal saline in the cleansing of acute and chronic wounds. Research on the effectiveness of wound cleansing (methods and solutions) is very limited. Pre-clinical studies have shown that some solutions (e.g., antiseptics) damage cells needed for wound healing. Fernandez, R., Griffiths, R. Water for wound cleansing. Cochrane Database of Systematic Reviews, February 15, 2012. DOI: 10.1002/14651858.CD003861.pub3 Moore, ZEH, Cowman, S. Wound cleansing for pressure ulcers. Cochrane Database of Systematic Reviews, March 28, 2013. DOI:10.1002/14651858.CD004983.pub Rodeheaver GT, Ratliff CR. Wound cleansing, wound irrigation, wound disinfection. In Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, Pa: HMP Communications, 2014:47-62. Downloadable at www.whywoundcare.com

Making Saline Solution at Home 1 teaspoon Salt 1 quart Water* or 8 teaspoons Salt 1 gallon Water* * Known, non-contaminated, safe water source

Commercial Wound Cleansing Solutions contain surfactants (surface active agents) Surfactants help to break the bonds between foreign bodies and the wound surface

Antimicrobial Solutions May be used in certain circumstances and/or for short periods of time - for infected wounds - for non-healable wounds - for palliative wounds © Diane L. Krasner Used with permission

Antimicrobial Solutions Examples: - Acetic Acid Dakin’s Solution Hydrogen peroxide Povidone-iodine Silver © Diane L. Krasner Used with permission Stop use when wound bed contains predominantly healthy tissues

Caution: Protect yourself from splash-back and prevent environmental contamination. Follow infection control measures for safe wound cleansing and irrigation: Gloves Masks / Face Shields PRN Gowns PRN Backsplash guard PRN

Cleanse or irrigate the wound at every dressing change (unless there is an order specifying not to)

Key Concepts Aseptic Care Assessment Caring Evidence-based Practice Healing Infection Infection Control Pain Prevention Safety Treatment

Key Diagnoses Alteration in Comfort r/t Impaired Skin Integrity Impaired Tissue Integrity Potential for Infection Potential for Injury

Key Practice Issues Nurses frequently assess and change dressings without cleansing the wound. Wound cleansing should be a step in every dressing change protocol, unless orders specify otherwise. Proper attention to infection control measures and splash-back is critical for safety reasons

Websites for Further Information on Wounds - Association for the Advancement of Wound Care www.aawconline.net - National Pressure Ulcer Advisory Panel www.npuap.org - Wound Healing Society www.woundheal.org - Wound Ostomy Continence Nurses Society www.wocn.org - Wounds Canada www.woundscanada.ca

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