Wounds: Cleansing and Irrigating Pediatric

  Procedure for pediatric wound care
Preparatory Phase

   1. Ensure that child and family understand procedure and questions are answered.
   2. Check prescribing practitioner's orders regarding wound care.
   3. Administer pre-medication per prescribing practitioner's order; use two patient identifiers when identifying child.
   4. Determine how many and what types of dressings are necessary; gather needed equipment and supplies.
   5. Perform hand hygiene.
   6. Have child lie in bed or place child on treatment table in a comfortable position, ensuring wound is visible and accessible; expose dressing.
   7. Ensure adequate lighting, privacy, and appropriate room temperature.
   8. Place dressing supplies on a clean flat surface. Open each dressing by peeling apart the edges of package, maintaining sterility; leave each dressing within the open package.
   9. Prepare tape.
  10. Position waterproof barrier under area to be dressed to collect drainage.
  11. Place disposable bag or receptacle nearby to collect soiled dressings.

Removing Old Dressing

   1. Put on clean gloves.
   2. Loosen all tape and gently pull tape ends toward the wound. Use adhesive removal pads as necessary.
   3. Remove all dressings, one layer at a time, and place in the appropriate disposal container.
   4. Assess wound bed for color, consistency, odor, and amount of drainage.
   5. Remove soiled gloves and discard in appropriate receptacle; perform hand hygiene.

Cleansing and Irrigating Wounds

   1. Perform hand hygiene; put on personal protective equipment.
   2. Position wound cleansing materials and soiled contamination container within easy reach.
   3. Establish sterile field; open sterile gauze and required supplies on field with aseptic technique.
   4. If irrigating wound, warm sterile water or NS to body temperature and place in a sterile container.
   5. Put on sterile gloves.
   6. Attach 18-gauge IV catheter (needle removed) to syringe for irrigation; draw up irrigating solution into syringe.
   7. With catheter kept 1 to 3 cm from wound surface, direct solution onto wound bed, irrigating from area of least to greatest contamination. Continue with irrigation until return solution is clear.
   8. When cleansing closed wound, use gauze moistened with sterile water or NS; cleanse from the top to base or center to edges; use new gauze with each area cleansed. Clean from least to greatest area of contamination.
   9. Dry intact skin around wound with sterile gauze.
  10. Discard used supplies and equipment in appropriate receptacle.
  11. Remove personal protective equipment; perform hand hygiene.

Dressing Open Wounds

   1. Gather needed equipment and supplies.
   2. Perform hand hygiene; put on appropriate personal protective equipment.
   3. Establish sterile field; open sterile gauze 4x4 pads and soak with NS.
   4. Put on sterile gloves; wring out 4×4 pads so they are damp, not dripping.
   5. Apply 4×4 pads over wound bed, gently packing gauze to wound edge; do not exceed wound edge.
   6. Cover moist packing with dry 4×4 pads or ABD.
   7. Secure dressing in place with tape or Montgomery straps.
   8. Tape:
   9. Apply across wound dressing and 1 to 2 inches beyond dressing onto skin.
  10. Montgomery straps:
  11. Apply liquid or hydrocolloid barrier to skin around wound where Montgomery straps will be placed.
  12. Remove paper backing from straps; apply to skin with gentle, even pressure.
  13. With criss-cross method, lace cotton tape (twill tape, umbilical tape, tracheostomy ties) through holes in Montgomery straps.
  14. Discard used supplies and equipment in appropriate receptacles.
  15. Remove personal protective equipment; perform hand hygiene.
  16. Document the procedure in the child's record.