10.3 Wound Care, Irrigation, Post-Care & Ambulation
Key Takeaways
- CMAC tasks 3.05.7–3.05.11 cover basic wound care (dressing change, bandaging, splinting), staple and suture removal, eye and ear irrigation, post-procedure patient instructions, and assistance with ambulation devices.
- Dressings cover and protect the wound; bandages secure dressings and support tissue—apply distal to proximal on limbs with even pressure, checking CMS (circulation, motion, sensation).
- Remove sutures/staples only with an order, after verifying timing and healing; clean the site, use proper staple remover or suture scissors/forceps, count removals, and apply Steri-Strips if ordered.
- Eye irrigation uses sterile solution, correct temperature, and flow from inner to outer canthus; ear irrigation requires intact tympanic membrane confirmation per protocol, warm solution, and controlled pressure—stop for pain or dizziness.
- Teach wound-care warning signs and activity limits; fit and coach canes, walkers, and crutches for safe gait (cane opposite weak leg; crutches with partial/non-weight-bearing patterns as ordered).
Closing the 3.05 Skill Set
Tasks 3.05.7–3.05.11 are hands-on ambulatory skills: wound care, closure removal, irrigation, discharge teaching, and ambulation devices. Together with Sections 10.1–10.2 they complete the 8% / ~13-item Assisting with Physical Examinations and Procedures domain.
3.05.7 — Basic Wound Care: Dressings, Bandages, Splints
Wound Assessment Before Care
Before any dressing change (with order/competency):
- Identify the patient; explain the procedure; hand hygiene and clean or sterile gloves per wound type/policy.
- Note location, size (length × width × depth when trained), wound bed (granulation, slough, eschar), drainage (serous, sanguineous, serosanguineous, purulent), odor, periwound skin, and pain.
- Compare with prior documentation; report deterioration (Section 10.2 infection signs).
Dressing vs Bandage vs Splint
| Term | Purpose | Examples |
|---|---|---|
| Dressing | Direct wound contact; absorb drainage; maintain moist or dry environment as ordered; protect from contamination | Gauze, nonadherent pads, hydrocolloid, transparent film, packing strip |
| Bandage | Holds dressing in place; supports/immobilizes; applies pressure | Roller gauze, elastic wrap, tubular bandage, tape |
| Splint | Immobilizes a body part to protect injury or post-procedure site | Prefabricated wrist/finger splints, posterior ankle splint, aluminum foam finger splint |
Dressing Change Principles
- Gather supplies before removing the old dressing (new dressing, saline if ordered, tape, waste bag).
- Loosen tape toward the wound; remove old dressing gently—if stuck, moisten with sterile saline as allowed.
- Inspect wound; cleanse per order (often sterile saline from clean to dirty, or center outward on surgical wounds).
- Pat dry periwound skin; apply skin protectant if ordered before adhesive.
- Apply new dressing without touching the wound-contact surface with bare hands.
- Secure; date/time/initial the outer dressing per policy.
- Document appearance, drainage amount/color, patient tolerance, and teaching.
Sterile vs clean dressing change: Fresh surgical wounds may require sterile technique; chronic dirty wounds may use clean technique—follow order and facility protocol.
Bandaging Rules
| Rule | Why |
|---|---|
| Distal → proximal on extremities | Supports venous return; standard application |
| Even pressure; no tight tourniquet effect | Prevents ischemia |
| Leave fingertips/toes exposed when possible | CMS checks |
| Secure end with tape/clips—not safety pins near skin carelessly | Safety |
| Recheck circulation, motion, sensation (CMS) after application | Catch numbness, coolness, duskiness, increased pain |
Common wraps: circular (anchor), spiral (uniform limb), spiral reverse (cone-shaped limb), figure-eight (joints), recurrent (stumps/head). Elastic compression for venous support is a provider order skill—too-tight ACE wraps cause harm.
Splinting Assist
- Verify order (which joint, which side, weight-bearing status).
- Pad bony prominences; immobilize the joint above and below the injury when that is the splint design goal.
- Do not wrap circumferential material so tightly that swelling cannot expand—many acute splints use continuous padding + splint + elastic wrap with CMS checks.
- Provide sling if ordered for upper extremity; teach elevation and ice if ordered.
- Document neurovascular status before and after.
3.05.8 — Staple and Suture Removal
Remove closures only with a provider order and when timing matches healing expectations (often ~5–10 days face, longer on extremities/joints—exact day is provider-determined).
Pre-Removal Checks
| Check | Action if problem |
|---|---|
| Order present | Do not remove “because the patient asks” alone |
| Wound edges well approximated without dehiscence | Stop; notify provider |
| Signs of infection | Notify provider before removal |
| Patient ID and site | Prevent wrong-site care |
| Allergy to tape/adhesive for Steri-Strips | Alternative securement |
Suture Removal Technique (General)
- Hand hygiene; clean gloves; cleanse site per protocol.
- Lift the knot with forceps; cut the suture close to the skin on one side so the least contaminated portion is pulled through tissue.
- Pull the suture out in one smooth motion; place on gauze to count total removed vs charted placed when count is known.
- Do not pull the visible contaminated external segment through the tract first if avoidable—cut to minimize dragging bacteria under skin.
- Apply adhesive wound-closure strips if ordered; dressing if ordered.
- Document number removed, wound appearance, and teaching.
Staple Removal
- Cleanse site.
- Place lower jaw of staple remover under the staple; squeeze to bend the staple and lift both ends from the skin.
- Do not pry with hemostats in a way that tears skin.
- Count staples; apply Steri-Strips if ordered.
- Some protocols remove alternate staples first, reassess, then remove remaining—follow order.
Interrupted vs continuous sutures: Continuous (running) sutures require understanding the pattern so the entire strand is removed without leaving buried segments—ask for help if the pattern is unclear. Absorbable sutures often are not removed; know what was placed from the procedure note.
3.05.9 — Eye and Ear Irrigation
Eye Irrigation
Used for chemical splash (emergency—often start ASAP per protocol), foreign body sensation with order, or discharge cleansing.
| Step | Detail |
|---|---|
| Order / emergency protocol | Chemicals may follow standing emergency irrigation protocols—know your clinic’s rule and when to call EMS/ophthalmology |
| Solution | Sterile saline or prescribed irrigant; room temperature to slightly warm—not hot |
| Position | Patient supine or head tilted toward the affected side; towel for runoff; basin at the cheek |
| Direction | Flow from inner canthus (near nose) to outer canthus so contaminant does not enter the other eye or nasolacrimal system preferentially |
| Technique | Hold lids gently; do not touch cornea with tip; continuous flow as ordered |
| After | Document solution, volume/time, patient response, visual changes; notify provider of pain, photophobia, or vision loss |
Contact lenses: remove if present and protocol allows before irrigation when safe to do so.
Ear Irrigation
Used for cerumen removal when ordered and not contraindicated.
| Contraindication / caution | Why |
|---|---|
| Known or suspected perforated tympanic membrane | Risk of middle-ear injury/infection |
| Tympanostomy tubes | Same concern |
| Severe otitis with pain | May worsen; provider decision |
| Vegetable foreign bodies that swell with water | Avoid water irrigation—specialist methods |
Technique outline:
- Verify order, ID, and that the provider has assessed the canal/TM as appropriate.
- Warm solution to body temperature to reduce vertigo (cold water → vestibular stimulation).
- Position patient sitting with head tilted; drape shoulder; emesis basin under ear.
- Straighten adult canal by pulling pinna up and back; for young children, down and back.
- Direct stream toward the canal wall, not straight at the tympanic membrane; use controlled pressure (ear syringe or irrigator per training)—never maximal force.
- Stop if severe pain, sudden dizziness, or bloody drainage; notify provider.
- Dry outer ear; document results and tolerance; recheck hearing/symptom relief as directed.
3.05.10 — Post-Procedure Patient Instructions
Teaching is a blueprint task of its own. Use plain language + written instructions + teach-back.
Wound / Procedure Aftercare Teaching Menu
| Topic | Sample teaching |
|---|---|
| Keep clean/dry | Exact hours before first shower; no soaking/swimming until cleared |
| Dressing changes | Frequency, clean technique, handwashing |
| Medications | Analgesics, topical antibiotics only as ordered; complete oral antibiotics if prescribed |
| Activity | Lifting limits, sport restrictions, work note per provider |
| Elevation / ice | For extremity procedures when ordered |
| Suture/staple return | Date for removal visit |
| Warning signs | Fever, spreading redness, pus, red streaks, wound opening, uncontrolled bleeding, severe pain, allergic rash to adhesive |
| When to call / ER | Uncontrolled bleeding, breathing difficulty after meds, signs of anaphylaxis, rapidly worsening infection |
Document what was taught and the patient’s understanding. Provide supplies (extra gauze, tape) when policy allows.
3.05.11 — Ambulation Devices
Assist patients with canes, walkers, and crutches for safe mobility after injury, surgery, or weakness. Fit and gait pattern follow the provider’s weight-bearing order: full, partial, toe-touch, or non-weight-bearing.
Device Fitting Snapshot
| Device | Fit cues |
|---|---|
| Cane | Top at wrist crease / greater trochanter height when arm hangs; elbow ~15–30° flexion; hold cane in hand opposite the weak/injured leg (unless provider specifies otherwise) |
| Walker | Handgrips at wrist crease; elbows slightly flexed; patient stands inside walker—do not use on stairs unless trained with stair protocol |
| Axillary crutches | 2–3 finger widths between axilla and pad; handgrip with elbow ~15–30° flexion; weight on hands, not armpits (prevents nerve injury) |
| Forearm (Lofstrand) crutches | Cuff below elbow; used for longer-term mobility needs |
Gait Patterns (High-Yield)
| Pattern | When / how (simplified) |
|---|---|
| Cane gait | Cane + weak leg forward together, then strong leg; on stairs: “up with the good, down with the bad” (cane supports the weak side) |
| Walker | Advance walker → weak leg → strong leg; do not step too far into walker |
| Three-point (NWB) | Both crutches advance with the injured leg non-weight-bearing; strong leg hops to |
| Four-point | Slow stable pattern: left crutch, right foot, right crutch, left foot |
| Two-point | Crutch and opposite foot advance together (more advanced coordination) |
Safety coaching: Non-skid shoes, clear pathways, rise from chair safely (walker: push up from chair, not pulling walker toward you), and guard on the weak/affected side when assisting ambulation. Report dizziness or new pain; use gait belt when policy and training support it.
Integrated Skills Example
A patient after ankle injury may need: sterile or clean dressing on a wound (3.05.7), temporary splint (3.05.7), crutches with non-weight-bearing instructions (3.05.11), and written wound-care warnings (3.05.10). If sutures were placed earlier, a later visit adds removal (3.05.8). Ear cerumen may be an unrelated same-day irrigation (3.05.9)—still verify TM status first.
Exam Traps for 3.05.7–3.05.11
| Trap | Correct idea |
|---|---|
| Bandage applied proximal → distal always | Standard limb wraps distal → proximal |
| Remove sutures because “day 7 is always right” | Timing is wound- and site-specific; need order |
| Ear irrigation with known TM perforation | Contraindicated |
| Eye irrigation outer → inner canthus | Inner → outer |
| Crutch weight on axilla | Weight through hands |
| Cane on the same side as the weak leg by default | Usually opposite the weak leg |
Master CMS checks, closure removal sequence, irrigation direction/temperature, teach-back aftercare, and device fit/gait—that finishes tasks 3.05.7–3.05.11 and the PE/procedures chapter.
When applying a roller bandage to secure a dressing on the forearm, which practice is most appropriate?
Which action is correct when removing interrupted skin sutures with an order present?
How should the medical assistant direct fluid during routine eye irrigation of one eye?
A patient with a left-leg injury is taught to use a single cane for partial support. Where should the cane normally be held?