PURPOSE: To promote wound healing that is being healed by secondary intention through mechanical debridement.

EQUIPMENT:

1. Non-sterile gloves
2. Sterile gloves
3. Kling(s) or Kerlix(s)
4. Sterile basin (optional)
5. Solution as ordered
6. ABD(s)
7. Instrument pack
8. Montgomery strips, abdominal binder, or tape
9. Absorbable pads (optional)

PROCEDURE STEPS:

1. Wash hands

2. Obtain and set up equipment following sterile technique.

3. Apply non-sterile gloves, and place pad to protect patient’s bed.
4. Remove soiled dressings, discard in a red biohazard bag and place in covered container.
5. Observe wound, amount, type, color of drainage and odor.  Assess the tissue in and around the wound.
6. Wash hands thoroughly
7. Apply sterile gloves.

KEY POINT: Maintain sterility of Kling/Kerlex utilizing one of the following methods:

a. Place Kling/Kerlix in sterile basin and pour solution over Kling/Kerlex
b. Gloved nurse holds Kling/Kerlex and assistant pours solution

 

8. Squeeze out excess solution.

9. Fanfold Kling/Kerlex ensuring base of wound and crevices are packed. Avoid placing wet dressing on skin. Wet dressing on skin will excoriate skin.
10. Kling/Kerlex should be just above skin level. Cut excess Kling with sterile scissors.
11. Cover wet dressing with ABD(s).
12. Dressing in appropriate manner; i.e., Montgomery straps, tape, stockinette or abdominal binder.
13. Document

RESOURCE PERSON(S): Joyce Randof, RNC, MNSc; Donella Doctor, RN, MNSc, CWOCN   
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