Wound Care Protocol based on wound appearance

These require PC order for treatment.

Wound Description

Necrotic Wound Cavernous or Under-minded – Tunneled Localized Infection/Critical Colonization

(Scab/Eschar/Dead Tissue) (Erythematous wound & surrounds,
increased drainage, possible odor,
increased pain)
Potentiate granulation from bottom up
Goal of Treatment Remove non-vital tissue chemically or and fill in dead space. Keep warm, Wound clean-up and reduce bacterial
mechanically moist & manage exudates. burden
MOD – HIGH EXUDATE:
Treatment MOD - HIGH EXUDATE: ** Treat underlying cause. MOD – HIGH EXUDATE:
Recommendations ** Treat underlying cause. ** Use Alginate/ Hydrofiber with ** Treat underlying infection. (Topical
** Use Alginate/Hydrofiber/foam/absorptive secondary absorbent or antibiotic or antifungal; systemic
dressing Hydrocapillary foam/ sponge on top. antibiotic - Rx)
Pack lightly, cover and secure. ** Use Silver alginate/ Alginate
** Wound VAC ** Protect surrounding skin
NONE - LOW EXUDATE: NONE – LOW EXUDATE:
**Use Debridement agent / Hydrogel / ** Pack lightly with Hydrogel gauze, NONE – LOW EXUDATE:
Hydrogel gauze/ Saline gauze. cover with secondary dressing, ** Silvadine cream topically (Rx)
**Sharp debridement (referral) secure. ** Silver wound contact layer
** Change daily.
IF >1x daily dressing changes required, Do NOT use Hydrogen peroxide, Acetic
Helpful Care Tips use of FOAM dressings as the Acid, Iodine, Dakin’s solution, Iodophor
cover/secondary dressing will help. unless specifically prescribed.
http://www.dressings.org http://www.dressings.org http://www.dressings.org
Helpful Links S:\I-Teams\Wound Care\Skin Care S:\I-Teams\Wound Care\Skin Care S:\I-Teams\Wound Care\Skin Care
Products.xls Products.xls Products.xls
(S:\I-Teams\Wound Care\Specialty Mattresses S:\I-Teams\Wound Care\Specialty S:\I-Teams\Wound Care\Specialty
03-2011.docx Mattresses 03-2011.docx Mattresses 03-2011.docx
S:\I-Teams\Wound Care\Specialist Referral, S:\I-Teams\Wound Care\Specialist
Guidelines for Wound Care Policy 12-2010.docx Referral, Guidelines for Wound Care Policy
12-2010.docx
[1]
 Wound Care Protocol
These require PC order for treatment

Wound Description
Sloughy Wound Macerated Skin Granulating Wound
(Pale layer of dead or fibrinous tissue over all (Soft, pale/white, wet or soggy skin (Wound bed filled with highly vascular,
or part of the wound bed) surrounding wound) fragile tissue)
Determine if present dressing regime is Support granulation and tissue growth
Goal of Treatment Remove non-vital tissue and management of absorbing exudates. Protect Keep wound warm and moist
drainage and exudates surrounding skin with barrier agent. Manage exudates
MOD – HIGH EXUDATE:
MOD - HIGH EXUDATE: ** Treat underlying cause. MOD - HIGH EXUDATE:
Treatment ** Treat underlying cause. ** Use alginate or Hydrofiber and ** Treat underlying cause.
Recommendations ** Use Cadexamer Iodines/ Alginates / secondary absorbent dressing. ** Use Alginates/Hydrofiber/Absorbent
Hydrofibers. ** Consider more frequent dressing pad/dressing.
** Use debridement agent changes.
** Apply barrier agent around wound NONE - LOW EXUDATE:
NONE - LOW EXUDATE: bed. ** Non-adherent dressing or
** Use Hydrogel/ Hydrogel gauze / Hydrocolloid.
Debridement agent if needed. NONE – LOW EXUDATE: ** Minimize dressing changes.
** This does not tend to occur in none
or low exuding wounds unless
dressing left on too long.
Minimize contamination from urine and
Care Tips feces
http://www.dressings.org http://www.dressings.org http://www.dressings.org
Helpful Links S:\I-Teams\Wound Care\Skin Care S:\I-Teams\Wound Care\Skin Care S:\I-Teams\Wound Care\Skin Care
Products.xls Products.xls Products.xls
S:\I-Teams\Wound Care\Specialty (S:\I-Teams\Wound Care\Specialty
S:\I-Teams\Wound Care\Specialty Mattresses Mattresses 03-2011.docx Mattresses 03-2011.docx
03-2011.docx S:\I-Teams\Wound Care\Specialist
Referral, Guidelines for Wound Care
Policy 12-2010.docx

[2]
 Wound Care Protocol
These require PC order for treatment

Standard NURSING Wound Care Protocol

Wound Description
Lymphedema with Venous Stasis Ulcer Epithelialization
(Edema due to an abnormality in the (The growth of new skin over the
lymphatic system, often involves one limb and wound)
is generally irreversible)
Goal of Treatment Control swelling, prevent skin ulceration and Protection and continued healing
promote wound healing

GENERAL CARE: MOD – HIGH EXUDATE:

Treatment ** Cleanse w/plenty of warm water; do not ** Care per appropriate protocol.
Recommendations soak for > 5min. Dry limb thoroughly, ** Protect surrounding skin.
especially between digits and crevices.
Gently remove dead skin/scaling. NONE – LOW EXUDATE:
** Apply Moisturizing Cream/Lotion to limb, ** Apply thin hydrocolloid wound
avoiding wound. contact layer or
** Choose wound dressing according to ** Cover w/film dressing and secure
wound appearance and protocols. with secondary dressing.
** Apply prescribed Compression Bandage. ** Change every 3 to 5 days and as
Wrap layers from base of toes to just needed, monitoring for change in
below tibial tuberosity for LE ulcers. progress or infection.
Change as prescribed, usually MWF.

DO NOT APPLY COMPRESSION BANDAGE Does require PC order for treatment

Care Tips UNLESS COMPETENT TO DO SO
http://www.dressings.org http://www.dressings.org
Helpful Links S:\I-Teams\Wound Care\Skin Care S:\I-Teams\Wound Care\Skin Care
Products.xls Products.xls
(S:\I-Teams\Wound Care\Specialty Mattresses S:\I-Teams\Wound Care\Specialty
03-2011.docx Mattresses 03-2011.docx
S:\I-Teams\Wound Care\Specialist
Referral, Guidelines for Wound Care
Policy[3]
12-2010.docx
 No PC order required.
“Applicable ONLY to Community Care Clinics”

Wound Description

Skin Tear Stage I Pressure Area Stage II Pressure Ulcer

(A break in the skin from friction, shear or (Non-blanchable erythema with intact (Partial thickness skin loss involving
trauma) skin) epidermis and/or dermis. Appears as
abrasion, blister or shallow crater)
To foster granulation and prevent infection or To prevent deterioration of skin To foster granulation and healing
Goal of Treatment further trauma integrity

Gently Cleanse. PREVENTION: BLISTER:

Treatment If skin flap present, use sterile Q-tip or tongue ** Position off affected area. ** Position off affected area.
Recommendations depressor to approximate edges. Use Steri- ** Keep area clean and dry. ** Gently cleanse, pat dry.
Strips to secure as needed. ** Apply protective cream, WITHOUT ** Cover with transparent dressing 2
MOD – HIGH EXUDATE: vigorous massaging over affected inches larger than ulcer. Apply
** Apply Adaptic, dry dressing to fit and wrap area. without tension or wrinkles. Change
with gauze to keep in place. Change daily HIGH FRICTION AREAS (i.e. heel, PRN.
prn. elbow) ABRASION/SHALLOW CRATER with
** Position off affected area. minimal to moderate amount of
NONE – LOW EXUDATE: ** Apply transparent dressing at least 2 drainage:
** Cover with transparent dressing. Avoid inches larger than affected area. ** Position off affected area.
significant overlapping onto healthy skin to Change prn or when redness ** Gently cleanse, pat dry.
prevent further trauma. Change q 5 to 7 resolves. ** Apply Hydrocolloid or Foam dressing
days and prn. ** Consider use of heel/elbow of appropriate size. Change q 5-7
protectors days and prn.

http://www.dressings.org http://www.dressings.org http://www.dressings.org

Helpful Links (S:\I-Teams\Wound Care\Skin Care (S:\I-Teams\Wound Care\Skin Care S:\I-Teams\Wound Care\Skin Care
Products.xls Products.xls Products.xls
S:\I-Teams\Wound Care\Specialty Mattresses S:\I-Teams\Wound Care\Specialty S:\I-Teams\Wound Care\Specialty
03-2011.docx Mattresses 03-2011.docx Mattresses 03-2011.docx
S:\I-Teams\Wound Care\Wound S:\I-Teams\Wound Care\Wound S:\I-Teams\Wound Care\Wound
documentation.docx documentation.docx documentation.docx

[4]
 Standard NURSING Wound Care Protocol
No PC order required.

General Wound Care Guidelines

1. The following general wound care guidelines should be followed for ALL members
with wounds. For specific treatments, see Wound Care Protocols.
2. Clean technique should be used for wound care. All wounds are considered
contaminated unless otherwise ordered.
3. Normal Saline is used to cleanse wound, unless contra-indicated. Cleanse prior to
Wound Description any wound assessment or new dressing application.
4. Apply Skin Protectant prep to wound borders and under any adhesive.
Fungal Skin rash 5. Select dressings that keep wound bed moist and peri-wound skin dry.
(Moist, macerated, erythemic plaques and 6. Document wound assessment weekly per policy and as needed when there is a
erosions found most commonly in folds of change.
abdomen, groin or breast. Satellite papules 7. Evaluate dressing selection and skin integrity with each dressing change.
commonly seen.) 8. Know the indications and contra-indications of the wound care products you are
Goal of Treatment Clean, dry skin without infection using. Utilize the www.dressings.org website.
PREVENTION: 9. Use care when removing all dressings and tapes to maintain progress of wound
Treatment ** Avoid causes of friction: tight or chafing healing. Use adhesive remover prn.
Recommendations clothes, activities causing skin on skin 10. Consider consultation with nutrition and rehab services.
rubbing, obesity. 11. Observe for signs and symptoms of infection:
** Maintain glucose control. Erythema, warmth and edema of the skin and tissue surrounding the wound
** Keeping skin clean, dry and protected. Pain or increased pain
** Management of causative factors such as Purulent drainage or foul odor
hygiene, urine or fecal incontinence. Fever, chills and malaise
REPORT symptoms of infection to PC
TREATMENT:
Adapted from 2004 Wound Care Guidelines, St. Joseph’s Community Hospital of West Bend .
** Cleanse and dry well before every
treatment.
Wound Protocol Reference List
** Apply Baza/Miconazole cream (from stock)
around and to affected area TWICE daily
1. St. Joseph’s Community Hospital of West Bend, WI. 2004. Skin and wound care
and as needed. treatment protocols.
** If no improvement after 3 to 5 days, 2. Wound, Ostomy and Continence Nurses Society. Various resources, website.
consult with PC. 3. Bakerjian, D & Levenson, S. 2008. Reducing pressure ulcers in NHs: An
interdisciplinary process framework. www.nhqualitycampaign.org
FUTURE PREVENTION:
4. Coloplast. 2007. Wound care reference guide. www.coloplast.com
** After resolution, Miconazole powder may
5. Northern Health and Social Services Board 2005. Sound management manual.
be applied to affected areas daily to
www.nhssb.n-i.nhs.uk/publications/primary_care/Wound_Manual.pdf
prevent recurrence. 6. Up-to-Date on line 18.2. 2010.
Helpful Links http://www.dressings.org
(Skin Care Products.xls)
S:\I-Teams\Wound Care\Wound
documentation.docx

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