Wound Care Protocol

PLACE LABEL HERE WOUND CARE PROTOCOL

The following orders will be implemented per physician order of a Wound Consult or per policy # 6106. Orders with a “” are indicator choices and are NOT implemented unless checked.

Location Type Stage POA Thickness Notes  Yes  No  Partial  Full  Yes  No  Partial  Full  Yes  No  Partial  Full  Yes  No  Partial  Full  Yes  No  Partial  Full  Yes  No  Partial  Full

1.  Consult Registered Dietitian to assess and manage. 2.  Float heels  Heel protectors  Pillow or waffle cushion when sitting  Place air overlay on bed 3. Positioning: turn q 2 hrs  Left  Right  Back 4. Clean wound with:  Normal Saline  Wound Cleanser 5.  Apply skin prep to periwound area 6.  Apply moisture barrier cream to periwound skin 7. DC these previously ordered topical medications: ______8. MEDICATIONS based on type of wound:  Fungal skin rash, antifungal barrier  cream or  powder: miconazole 2%, apply topically bid and prn  Peri-Wound Itching/Dermatitis: Mycolog (nystatin, triamcinolone) cream, apply topically BID  Friction/shear or pressure ulcer on buttocks: Venelex (balsam, castor oil), apply bid  Pink/Red Wound Bed: Apply wound gel topically daily  High risk for infection: Apply silver contact layer to open wound  Purulent drainage and periwound erythema: Silvadene cream (silver sulfadiazine) apply topically daily  Abrasion due to trauma (road rash): Apply Bacitracin to open wound(s) BID  Purulent drainage, periwound erythema and foul odor: Dakins Solution (sodium hypochlorile) 1/4 strength to moisten gauze and apply topically daily. Gently tuck gauze into any tunnels.  Non-viable tissue: Santyl (collangenase) apply topically daily, for chemical debridement  Closed Wound edges: Certified Wound Care Nurse (WOCN) to apply Silver Nitrate topically prn  Stable eschar: paint wound with Betadine Topical Solution (povidone iodine) daily  Diabetic foot ulcers: Iodosorb (cadexomer, iodine) apply to open wound daily 9.  Necrotic /Nonviable tissue: Certified Wound Care Nurse (WOCN) to perform sharp excisional debridement with scissors/scapel prn 10 Cover wound with (policy # 6106):  Dry gauze  Absorbent Foam  Hydrocolloid  Silicon dressing  Elastogel  ABD pad  Adaptic/Non-adherent gauze  Other: ______11. Secure dressing with:  Tape  Roll gauze  Stretchnet 12. Change dressing q: ______day(s)  BID  Other: ______ADDITIONAL INSTRUCTIONS: ______

______Date Time Physician Signature PID Number Copy to pharmacy

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