Increasing redness, warmth, purulent drainage, foul odor, or fever signals infection; report.
Before you read
Test yourself first: 4 questions
Question 1 of 4
A nurse is teaching a nursing student about wound healing. The nurse explains that a clean surgical incision with edges approximated by sutures heals by which type of intention?
Answer: C. Primary intention healing occurs when wound edges are well approximated (as with sutures, staples, or adhesive), there is minimal tissue loss, and healing is rapid with little scarring. Secondary intention applies to open wounds that heal by granulation; tertiary (delayed primary) closure is used for contaminated wounds closed later.
Question 2 of 4
A client sustains an open (sucking) chest wound from a stabbing. While awaiting the provider, which initial dressing does the nurse apply?
Answer: B. An open chest wound is initially covered with a sterile occlusive dressing taped on three sides, creating a flutter-valve effect that lets air escape on exhalation but prevents air entry on inhalation, reducing the risk of a tension pneumothorax. A fully sealed dressing can trap air and cause tension.
Question 3 of 4
A nurse is preparing to obtain a wound culture from an infected pressure injury. Which technique yields the most accurate specimen?
Answer: A. The wound should first be cleansed with normal saline to remove surface contaminants, then the swab is rotated over clean viable granulation tissue, not over slough, eschar, or pus. Culturing exudate or pus alone reflects surface colonizers rather than the organisms invading the tissue.
Question 4 of 4
A public health nurse responds to a community disaster and performs triage. Using disaster triage principles, which victim should receive care FIRST?
Answer: B. In disaster triage, the goal is the greatest good for the greatest number, prioritizing victims with serious but survivable injuries. A client with a tension pneumothorax has a life-threatening but treatable condition and should be treated first. The walking-wounded can wait, and a victim with massive nonsurvivable injuries and no respirations is categorized as expectant.
Keep the streak going with more questions like these, each with a full rationale.
What is wound irrigation?
It uses sterile technique for open or surgical wounds and gentle, controlled pressure. Key principle: irrigate from clean to dirty, top to bottom, until the return runs clear.
Key points to remember
- Normal saline is the preferred, non-toxic irrigant; avoid cytotoxic agents on healthy granulation tissue.
- Use a 35 mL syringe with a 19-gauge angiocatheter to deliver safe, effective pressure (about 4 to 15 psi).
- Position the client so solution flows from the cleanest (top) area toward the most contaminated (bottom) area and into a basin.
- Hold the syringe about 1 inch above the wound and irrigate until the return is clear.
- Use sterile technique for sterile wounds; warm the solution to near body temperature for comfort and healing.
- Assess and document wound bed color, size, drainage, and surrounding skin before and after.
Nursing priorities
- Assess the wound and pre-medicate for pain if the procedure is expected to be painful.
- Set up sterile field and use clean-to-dirty, top-to-bottom irrigation direction.
- Irrigate gently with continuous low pressure until returns are clear.
- Dry surrounding skin, apply the ordered dressing, and document wound appearance.
- Monitor for signs of infection and impaired healing at each dressing change.
Labs & values
Patient teaching
- Keep the dressing clean and dry and report increased pain, redness, swelling, or drainage.
- Eat adequate protein and vitamin C and stay hydrated to support healing.
- Wash hands before and after any contact with the wound or dressing.
Red flags: report now
- Increasing redness, warmth, purulent drainage, foul odor, or fever signals infection; report.
- Sudden increase in serosanguineous drainage or visible wound edge separation (dehiscence/evisceration) is an emergency; cover with sterile saline-soaked gauze and call provider.
- Never irrigate with high pressure or push irrigant into a deep/tunneling wound forcefully.
References
Clinical references for this topic
