IN CARE PROTOCOL BY COMPREHENSIVE WOUND CARE SERVICES [email protected]@cwswounds.com Certified| Cost Control | Compassion We Heal Wounds
Wound Images
Wound Suspected Deep Tissue Stage I Pressure Stage II Pressure Ulcer or Stage III Ulcer or Full Thickness Wound Type Injury Ulcer Partial Thickness wound
Definition sDTI – Purple or maroon localized Intact skin with non- Stage II or Partial thickness loss of Stage III or Full Thickness – Full Stage IV or Full Thickness – Full area of discolored intact skin or blanchable redness dermis presenting as a shallow open thickness tissue loss. Subcutaneous thickness tissue loss with exposed bone, blood filled blister due to damage of a localized area ulcer with a red pink wound bed, without fat may be visible but bone, tendon tendon or muscle. Slough or eschar may of underlying soft tissue from usually over a bony slough. May also present as an intact or muscle are not exposed. Slough be present. Often includes undermining pressure and/or shear. The area prominence. Darkly or open/ruptured serum-filled or sero- may be present but does not and tunneling. The depth of a Stage may be preceded by tissue that pigmented skin may sanguinous filled blister. Presents as a obscure the depth of tissue loss. IV pressure ulcer varies by anatomical is painful, firm, mushy, boggy, not have visible shiny or dry shallow ulcer without slough May include undermining and location. The bridge of the nose, ear, warmer or cooler as compared blanching; it’s color or bruising*. This stage should not be tunneling. The depth of a Stage III occiput and malleolus do not have to adjacent tissue. Deep Tissue may differ from the used to describe skin tears, tape burns, pressure ulcer varies by anatomical (adipose) subcutaneous tissue and these injury may be difficult to detect in surrounding area. The incontinence associated with dermatitis, location. The bridge of the nose, ulcers can be shallow. Stage IV ulcers can individuals with dark skin tones. area may be painful, maceration or excoriation. *Bruising ear, occiput and malleolus do not extend into muscle and/or supporting Evolution may include a thin firm, soft, warmer or indicated deep tissue injury. NPUAP 2014 2019 have (adipose) subcutaneous tissue structures (e.g. fascia, tendon or joint blister over a dark wound bed. cooler as compared to and stage III ulcers can be shallow. capsule) making osteomyelitis or osteitis The wound may further evolve and adjacent tissue. Stage In contrast, areas of significantly likely to occur. Exposed bone/muscle is become covered by thin eschar. I may be difficult to adiposity can develop extremely visible or directly palpable. NPUAPNPUAP 2014 2019 Evolution may be rapid exposing detect in individuals deep Stage III pressure ulcers. of additional layers of tissue even with dark skin tones. Bone/tendon is not visible or with optimal treatment. May indicate “at risk” directly palpable. NPUAP 2014 2019 NPUAP 2019 persons. NPUAPNPUAP 2014 2019
Treatment Dry to Scant Moderate to Dry to Scant Moderate to Heavy Heavy
PREVENTION GUIDELINES CLEANSE CLEANSE CLEANSE CLEANSE • Saline • Saline • Saline • Saline • Pressure redistribution support surface as appropriate • Turn and reposition q 2h in bed and q 1h in chair PREP PREP PREP PREP • Offloading device to keep heels elevated off bed • Surprep • Surprep No-Sting • Surprep No-Sting to periwound • Surprep No-Sting to periwound skin • Monitor skin at least q 8hrs No-Sting to to periwound skin skin periwound skin FILL APPLY APPLY • Opticell – change Q 3-5 days and PRN PREP, IF APPROPRIATE Debridement agent, qdaily APPLY • Exuderm • Debridement agent, qdaily OR • No sting sure prep • Skintegrity Odorsheild – COVER Hydrogel – change Q 3-5 days MOISTURIZE, IF APPROPRIATE FILL, IF NEEDED • Bordered Gauze Change Q and PRN • Optifoam/Optifoam Gentle • Remedy Nourishing Skin cream 3days and PRN OR • Skintegrity Hydrogel and Gauze – change Q 3 days and PRN • Optifoam/ **STALLED WOUNDS – PARTIAL/FULL PROTECT, IF INCONTINENT COVER Optifoam Gentle – THICKNESS • Moisture Barrier ointments and protectants, as appropriate COVER • Bordered change Q 3-5 days • Puracol Plus – Change Q 3-5 days and 1 of 3 Gauze • Bordered Gauze and PRN • Optifoam/Optifoam Gentle PRN
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Wound Images
Wound Unstageable Pressure Ulcers Necrotic Skin Tear Type 1 or 2 Skin Tear Type 3 Colonized or Infected Wounds Type wounds
Definition Unstageable – Full thickness skin or tissue loss - Depth Type 1 – No Skin Loss. Linear Type 3 – Total Flap Loss. Entire Colonized – Presence Infected – represents unknown. Full thickness tissue loss in which actual depth of the or flat tear which can be wound bed is exposed of bacteria that cause no the invasion of bacteria ulcer is completely obscured by slough (yellow, tan, gray, green repositioned to cover the wound NPUAP 2019 local or systemic signs or into healthy tissue or brown) and/or eschar (tan, brown, or black) in the wound bed symptoms. where they continue to bed. Until enough slough and/or eschar are removed to expose Type 2 – Partial Flap Loss. Flap proliferate and cause a the base of the wound, the true depth can not be determined; cannot be repositioned to cover reaction from the host – but it will be either a Stage III or IV. Stable (dry, adherent, intact the wound. will typically show signs without erythema or fluctuance) eschar on the heels serves NPUAPNPUAP 2014 2019 of clinical infection, as “the body’s natural (biological) cover” and should not be need Topical/Systemic removed. NPUAPNPUAP 2014 2019 ABX
Treatment All Levels Dry to Scant Moderate to Heavy Dry to Scant Moderate to Heavy
• Solid Dry Eschar on OTHER NECROTIC WOUNDS CLEANSE CLEANSE CLEANSE CLEANSE Heels – No dressing, • Saline • Saline • Saline • Saline keep dry CLEANSE • Saline PREP PREP PREP PREP • Surprep No-Sting to • Surprep No-Sting to • Surprep No-Sting to • Surprep No-Sting to PREP periwound skin periwound skin periwound skin periwound skin • Surprep No-Sting to periwound skin APPLY APPLY FILL APPLY • Skintegrity Hydrogel, change • Optifoam Gentle, change Q • SilvaSorb Hydrogel, • Opticell Ag, change Q APPLY Q 3 days and PRN 3-5 days and PRN change Q 3 days and 3-5 days and PRN • TheraHoney – change Q 3-5 PRN days and PRN COVER COVER • Rolled Gauze/tape COVER • Bordered Gauze or COVER OR • Bordered Gauze Optifoam Gentle • Bordered Gauze, Optifoam APPLY Debridement agent Antibiotic Powder Gentle • Optifoam Gentle – Change Q 3-5 days and PRN with debridement agent. ABX PO as per PCP 2 of 3
IN CARE PROTOCOL BY COMPREHENSIVE WOUND CARE SERVICES [email protected]@cwswound.com Certified| Cost Control | Compassion We Heal Wounds
Routine High Risk Skin Incontinence Incontinence Associated Weepy Edema Intertrigo Fungal Rash Skin Care Dermatitis (IAD)
Everyday Skin care for those at high risk Moisture barrier for Skin protectant and treatment for Protectant barrier Protection and treatment Protection and treatment skin care for for breakdown or for sensitive those patients who are those patients who are incontinent and treatment for for areas exposed to of fungal rash patients with skin incontinent to provide and where skin is compromised or with compromised, weepy friction and moisture where no skin related protection where skin is epidermal skin loss. skin there is skin to skin contact issues intact.
Current Current Current Current Current Current
1. Cleanse and dry area thoroughly 1. Cleanse and dry area 1. Cleanse and dry area thoroughly 1. Cleanse and dry area 1. Cleanse and dry area 1. Cleanse and dry area 2. Apply skin cream while skin is damp, when thoroughly 2. Protect skin after cleansing with skin thoroughly thoroughly thoroughly possible 2. Protect skin after protectant paste 2. Apply skin 2. Apply skin protectant 2. Apply anti-fungal 3. Apply skin cream only to point where cream cleansing wit barrier 3. Apply skin protectant paste to protectant paste to paste to denuded or powder or cream to disappears cream denuded or macerated skin until compromised weepy macerated skin until fungal rash 4. Avoid massaging red, bruised, or discolored skin, 3. Apply barrier cream to entire area is covered skin entire area is covered 3. Consider treating fungal or over a bony prominence intact skin and reapply 4. Utilize a thin layer, and cleanse 3. Avoid putting skin 3. Implement measured rash for 14 consecutive as needed protectant paste in to prevent friction and days, even if rash 5. Inspect skin for signs of breakdown especially soiled area only until clean. It is not over bony prominences and under breasts, 4. Inspect skin with each necessary to remove all of the skin between the toes moisture in skin fold improves abdominal folds, axilla areas, heels and ankles cleansing to identify protectant paste areas 6. Remove socks or support hose daily to inspect early breakdown 5. Inspect skin with each cleansing 4. May also need anti- fungal treatment feet for signs of pressure or skin breakdown
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1. Bathe with Soothe and Cool Herbal Shampoo 1. Cleanse with Aloe 1. Cleanse with Aloe Touch Personal 1. Cleanse with Aloe 1. Cleanse with Aloe Touch 1. Cleanse with Aloe and Body Wash. Dry area thoroughly Touch Personal Cleansing Wipe. Dry area touch Personal Personal Cleansing Touch Personal 2. Apply Remedy Phytoplex Nourishing Skin Cream Cleansing Wipe. Dry thoroughly Cleansing Wipe. Dry Wipe. Dry area Cleansing Wipe. Dry while skin is damp, when possible. area thoroughly 2. Apply Remedy Phytoplex Z-Guard area thoroughly thoroughly. area thoroughly • Apply moisturizing only to point where lotion/ 2. Apply Remedy to protect compromised skin after 2. Apply Remedy 2. Apply Remedy 2. Apply Remedy cream disappears Phytoplex Hydraguard cleansing. Phytoplex Z-Guard Phytoplex Z-Guard to Phytoplex Anti-fungal • Avoid massaging red, bruised, or discolored to protect intact skin • Apply skin protectant to denuded to protect wet, denuded or macerated Clear to affected area after cleansing and weepy, draining skin. and reapply twice daily. skin, or over a bony prominence or macerated skin reapply as needed areas of the legs • Inspect skin for signs of breakdown especially • Utilize a thin layer, and cleanse • Implement measured • Consider treating over bony prominences, and under breasts, 3. Inspect skin with each soiled area only until clean. It is • Avoid putting to prevent friction and fungal rash for 14 abdominal folds, axilla areas, heels, ankles cleansing to identify not necessary to remove all of the skin protectant in moisture in skin folds consecutive days, early breakdown. between the toes even if rash improves. • Remove socks or support hose daily to inspect skin protectant. • May also need anti- feet for signs of pressure or skin breakdown • Inspect skin with each cleansing fungal treatment
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