DELAWARE TECHNICAL COMMUNITY COLLEGE
NURSING DEPARTMENT
Performing sterile irrigation of a wound and applying a wet to dry dressing
Goal: The wound will be cleaned without contamination or trauma and dressing will be applied without
causing tissue trauma and causing the patient undue pain.
*Indicates a critical behavior that must be performed in order to pass the skill successfully.
1. *Review the primary care provider’s (PCP) order for wound care with irrigation and repacking the
wound.
2. *Thirty minutes before the dressing change, enter the patient’s room and perform hand hygiene.
Identify the patient. Ask to see their arm band and ask them to state their name and date of birth. Ask if
they have any allergies.
3. Assess the patient’s pain using the 0-10 pain scale. If needed, administer appropriate analgesic as
ordered and document on the MAR.
4. *Gather necessary supplies.
5. *Return in 30 minutes and perform hand hygiene.
6. *Identify the patient. Ask to see their arm band and ask them to state their name and date of birth. Ask
if they have any allergies. Reassess the pain level using the 0-10 pain scale.
7. Explain the procedure to the patient.
8. Close the door or curtains. Place the bed at a comfortable working height.
9. Have the disposal bag or waste receptacle within easy reach prior to the irrigation for soiled dressing
disposal.
10. *Don a gown, mask, and eye protection. (PPE)
11. *Put waterproof absorbent pad under the wound area.
12. Assist the patient to a comfortable position that provides easy access to the wound area. Position
the patient so that the irrigation solution will flow from the wound during irrigation. Expose only the area
you need.
13. *Put on clean disposable gloves. If there is tape with writing on the dressing, read what’s written.
Remove the soiled dressings being careful not to pull the skin. Note the size and number of gauze you
removed.
14. *After removing the dressing, note the color, odor, amount and type (COAT) of any drainage on
the dressings. The amount could be scant, moderate or copious. The type may be serous (goldish
clear), serosanguineous (pink), sanguineous (red blood), or purulent (pus). Place soiled dressings in the
appropriate waste receptacle. Assess the wound bed for the presence of eschar, granulation tissue,
undermining, tunneling, necrosis and slough. Assess the appearance of the surrounding tissue.
Measure the wound (length – head to toe, width- hip to hip, and depth LxWxD). Note the stage of the
wound.
15. *Dispose of gloves. Perform hand hygiene (gel at the bedside) or lower the bed, put up the side rail and
go wash hands.
16. *Using sterile technique, prepare a sterile field. Open the sterile drape holding only the outer one
inch edge and lay on table. Open and place the 4x4s, ABD pad, and the irrigation bulb and container on
the center of sterile field. Be sure to stay away from the one-inch border. Set the bulb syringe tray on the
table (do not touch the inside of the tray). Leaving the bulb syringe on the sterile field, lift the irrigation
container and set on the table. Pour sterile irrigation solution into the sterile irrigation tray and the
irrigation container.
17. *Don sterile gloves. Your hands must remain above your waist and in front of you at all times. Your
hands may not cross over one another. Separate the supplies on the sterile field. Then pick up the
syringe by the bulb.
18. *Pretend to fill the syringe with solution and gently direct a stream of solution into the wound. Keep the
tip of the syringe at least one inch above the upper tip of the wound. (Never point the tip directly at the
wound).
19. *The solution should flow smoothly and evenly. When the solution from the wound becomes
clear, discontinue irrigation. Allow excess fluid to drain from wound bed. If excessive fluid remains in the
wound bed, you may wick it out. You must not contaminate your sterile gloves with the moisture! Gently
set a folded sterile gauze in the fluid. Do not disrupt the tissue integrity by moving the gauze. Remove
before the fluid is halfway up the gauze.
20. Pick up some of the 4x4s and place in to the irrigation tray solution. Squeeze excess fluid from the
gauze dressing. Unfold and fluff the dressing.
21. *Gently and loosely place the moistened gauze into the wound. Ensure that all areas of the wound bed
are in contact with the moistened gauze to prevent the tissue from drying out and forming a scab.
22. Dry the surrounding skin with sterile gauze.
23. *Apply dry, sterile gauze pads over the wet gauze. The outer skin must remain dry to prevent
breakdown of healthy intact tissue.
24. *Place the ABD pads over the gauze. Secure the dressing on all sides with tape. According to agency
policy, write the date, time and your initials on a piece of tape and place it on the tape border. We
NEVER write on a patient’s dressing.
25. Remove absorbent pad from under patient.
26. *Remove and discard gloves.
27. *Place the patient in a comfortable position with side rails up, bed in the lowest position, call bell within
reach and brakes locked.
28. *Clean up supplies and perform hand hygiene.
29. *Document the dressings you removed, COAT for the drainage, the wound bed and surrounding
borders, the measurements, that you irrigated the wound, the dressing you put in/on the wound, how the
patient tolerated the procedure.
Adapted: Burton, M. & Smith, D (2023). Davis Advantage for Fundamentals of Nursing Care: Concepts, Connections, and
Skills. Philadelphia, PA: FA Davis
