A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound. Which actions by the new nurse would require the experienced nurse to intervene? Select all that apply. A)Administers the prescribed analgesic 30 minutes before irrigating the wound B)Cleanses the wound from the most to the least contaminated area C)Obtains a 10-mL syringe and a 27-gauge needle D)Reviews the child's most recent immunization record E)Uses continuous pressure to irrigate and repeats until drainage is clear

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11ecbb05_cb7e_8637_b433_d5b7910a66e6_MD0009_00 Before an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment (eg, playground) as contamination with soil or dirt greatly increases the risk of infection. To perform wound irrigation: Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect (Option A). Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area. Use continuous pressure to flush the wound, repeating until drainage is clear (Option E). Dry the surrounding wound area to prevent skin breakdown and irritation. Immunization history is reviewed to determine tetanus vaccination status (Option D). Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on the contamination level of the wound. (Option B) Wounds should be cleaned from the least to the most contaminated area to prevent recontamination. (Option C) A 10-mL syringe would require frequent refilling; a larger syringe is more appropriate. The narrow lumen of a 27-gauge needle would provide excessive irrigation pressure. Educational objective: Open wounds must be free of dirt and bacteria prior to closure to reduce the risk of infection. Wound irrigation requires surgical asepsis.

A 7-Year-Old Client Receives a Scalp Laceration to the Back