Question

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take?

a. Apply a wet-to-dry gauze dressing.
b. Irrigate with hydrogen peroxide solution.
c. Use a 30-ml syringe.
d. Attach a 24-gauge angiocatheter to the syringe.

Answer 1

The nurse should use a 30-ml syringe to irrigate a clean, granulating wound, avoiding wet-to-dry dressings, hydrogen peroxide solution, and forceful irrigation.

Step-by-step explanation:

When a nurse is planning to irrigate and dress a clean, granulating wound for a client with a pressure injury, the appropriate action to take is to use a 30-ml syringe. This size of syringe allows for sufficient irrigation without exerting excessive pressure that could damage the granulating tissue. Applying a wet-to-dry gauze dressing is typically avoided in clean, granulating wounds because it can disrupt the healing tissue when removed. Irrigating with hydrogen peroxide solution is not recommended for regular wound care as it can impede healing and potentially cause tissue damage. Attaching a 24-gauge angiocatheter to the syringe can provide a focused stream of fluid which might be too forceful and could damage the delicate granulation tissue.