cleansing of a wound

[pattc]

Hi Everyone

This is a sort of poll but I am looking for opinions/advice.

Everyone knows an incision is cleaned first with wound care starting from the cleanest to the dirtiest.

I have a conundrum. If the wound is placed in a position where the N/S can flow back over the previously cleaned wound ( bringing skin flora with it) which is the best method to use? eg horizontal wound on upper torso and patient cannot lie back so must remain in fowlers or semi fowlers

I feel cleaning over the wound first would give the opportunity to limit skin debris from settling into the wound, especially now that drying the wound itself is not recommended. So, for this type of wound I would clean (first) top area over the wound (second) wound itself (third) lower area under the wound.

area over the wound ----------- (1st)

wound ________ (2nd)

area under the wound ---------- (3rd)

I have had agreement with IC staff and surgeons but disagreement with peers. I have found little documentation on this subject

Let me know your opinions.... especially wound care specialists

Thanks

Pattc

[optimist]

If Im picturing this correctly, is it a horizontal surgical incision (wide and narrow?) If so I would first cleanse the periwound with an antiseptic wound cleanser (antisept,silvermed wound cleanser,etc) then I would use a large gauge needle and syringe filled with NS (or your wound cleansing product of choice) to directly cleanse the wound. The pressure from the syringe will debride the wound of dead cells.

[DookieMeisterRN]

I'm confused, if the pt is in a semi fowlers or fowlers how can the NS flow back?

[pattc]

What happens is fluid from the swab used for cleaning (unless it's nearly dry or little to no pressure is applied) flows over the already cleaned incision through gravity if the person is in an upright position. Picture a mastectomy incision and the patient is sitting erect. How and where would the fluid flow?

Optimist would use the same technique that I would use.

[DookieMeisterRN]

I really don't know how something would flow uphill if the pt is erect. I must be missing something :/

[pattc]

LOL. ... the person is erect so cleaning the incision first Then the area directly above the incision will cause downward gravity flow into the incision. Picture the mastectomy scenario with the patient sitting erect to have the dressing changed. Unless the swab is dry, it is likely fluid will flow downward towards her lower torso. Therefore, cleaning the area above the incision FIRST will result in gravity flow of N/S carrying skin flora toward the lower torso and over & into the incision

[DookieMeisterRN]

LOL. ... the person is erect so cleaning the incision first Then the area directly above the incision will cause downward gravity flow into the incision. Picture the mastectomy scenario with the patient sitting erect to have the dressing changed. Unless the swab is dry, it is likely fluid will flow downward towards her lower torso. Therefore, cleaning the area above the incision FIRST will result in gravity flow of N/S carrying skin flora toward the lower torso and over & into the incision

I've never used so much NS or whatever cleanser above a wound to make it drip into the incision. That's what I'm having difficulty understanding. It's not like you're flushing NS all willy-nilly across the pts whole torso? To an extent you should be able to have some degree of control of the situation.....and your cleansing solution.

Just my .02.

[xtxrn, ASN, RN]

If Im picturing this correctly, is it a horizontal surgical incision (wide and narrow?) If so I would first cleanse the periwound with an antiseptic wound cleanser (antisept,silvermed wound cleanser,etc) then I would use a large gauge needle and syringe filled with NS (or your wound cleansing product of choice) to directly cleanse the wound. The pressure from the syringe will debride the wound of dead cells.

Huh?

How do you have an incision that is wide AND narrow?

Otherwise, do what IC says or have the patient turn around :)

[pattc]

I've never been able to wring out a swab enough to prevent some spillage over the surrounding skin, or in this case, the wound, due to the close proximity. The swab would have to be dry to prevent even this minimalistic amount, which defeats the purpose. It's not like a bucket of water has been splashed all over them. And skin flora are microbial and need little mode of transmission to move alot of bugs

[xtxrn, ASN, RN]

I've never been able to wring out a swab enough to prevent some spillage over the surrounding skin, or in this case, the wound, due to the close proximity. The swab would have to be dry to prevent even this minimalistic amount, which defeats the purpose. It's not like a bucket of water has been splashed all over them. And skin flora are microbial and need little mode of transmission to move alot of bugs

If you wring it out that much, you lose the 'juice' to do the full cleansing. Can you adjust the pressure you're using? I've never had a situation where THAT much cleansing solution was an issue... ? You're going to have some dripping. You can minimize, but not really eliminate every drop - true, it doesn't take much fluid to move bugs, but skin is never going to be sterile...you can only do a prudent, reasonable job of it- not eliminate all fluid during wound care.

Some wound care involves total submersion. Others, wet-to-dry dressings. The wound can still heal without infection if there's some fluid. Just do the best you can

[sarsan]

Studies show that tap water is just as effective as normal saline in cleansing wounds.