This is a copy of a PowerPoint presentation on revision of protocols, or rather implementing some where there are none

This is a copy of a PowerPoint presentation on revision of protocols, or rather implementing some where there are none. Facility had limited flexibility, adamant on a few things, and limited formulary. Changing from all PT wound care to nursing when nursing doesn’t even do assessments on wounds yet. Modify and use any way you want, I wasn’t paid to do this, so no one has rights……..Barbara Dale RN BSN CWCN

Sample Wound Protocols

•Partial thickness

•Full thickness

•Dry Necrotic wounds

•Wet necrotic wounds

•Venous leg ulcers

•Arterial leg ulcers

•Diabetic ulcers

•Skin tears

Skin Integrity Interventions

•Assesments:

–Risk assessment, i.e. Braden, daily

–Complete skin assessment per shift

–Wound assessments daily or as ordered

Skin Integrity Interventions

•Nursing Interventions:

–If incontinent, use of barrier cream, i.e. aloe vesta

–Float heels on all at risk patients

–Turning schedules for at risk patients

–Suggest nutritional consult for at risk patients

–Wound care per protocol or MD order

Skin Integrity Interventions

•Wound Care Protocols

–Stage I

•Reddened that does not blanch when pressed with finger. Discoloration does not resolve within 30 minutes when pressure is relieved.

–Nursing Care:

vMay use transparent film over wound

vDocumentation

Skin Integrity Interventions

•Wound Care Protocols

–Stage II, Partial thickness

•Loss of epidermis. May present as blister or shallow crater.

–Nursing Care:

vDraining: Clean with Saf-Clenz wound cleanser, pat dry with 4 X 4 gauze, cover with Combiderm. Change dressing Q 3rd day or when exudate strikes through.

vNon-draining: Clean with Saf-Clenz wound cleanser, pat dry with 4 X 4 gauze, cover with transparent film. Change Q 3^rd day and PRN dislodgement.

vConsider use of topical ointments, i.e., Xenaderm, for large areas.

vDocumentation

Skin Integrity Interventions

•Wound Care Protocols

–Stage III, Full thickness

•Full thickness skin loss, damage penetrating into SQ tissue. May present as deep crater.

–Nursing Care:

vDraining: Clean with Saf-Clenz wound cleanser, pat dry with 4 X 4 gauze, if wound has dead space: pack loosely with Aquacel, cover with Combiderm. Change dressing QOD or when exudate strikes through Combiderm.

vNon-draining: Clean with Saf-Clenz wound cleanser, pat dry with 4 X 4 gauze, if wound has dead space: pack loosely with hydrogel saturated packing strips, cover with Combiderm. Change QOD and PRN dislodgement.

vLoosely pack any undermining or tunneling with packing strips to obliterate dead space.

vDocumentation

Skin Integrity Interventions

•Wound Care Protocols

–Stage IV, Full thickness

•Full thickness skin loss with extensive damage, necrosis, or damage to bone, muscle, or supporting structures such as joint or tendon. If necrotic material is present, staging cannot be done until wound base is visible.

–Nursing Care:

vObserve for s/sx of infection-consult PT or notify MD

vDraining: Same as Stage III, change daily.

vNon-draining: Same as Stage III.

vDry eschar: If firm without s/sx infection, protect from trauma, keep clean and dry. Do not apply products that would soften eschar on wounds of ischemic/arterial etiology, or on the lower extremities of diabetic persons. Do not remove dry firm eschar on heels.

vDry eschar: If boggy or s/sx of infection, clean with Saf-Clenz, pat dry with 4 X 4 gauze, apply hydrogel and cover with Combiderm. Change daily. Consider use of chemically debriding dressing such as Mesalt or Hypergel (MoInlycke) covered with combiderm and to be changed daily or an enzymatic debrider [Accuzyme, Panafil, Santyl, Gladase) changed daily.

vConsider use of wound vac{KCI} to promote granulation for large wounds, surgical dehisced wounds, diabetic foot ulcers, and venous disease unable to tolerate compression.

vDocumentation

Skin Integrity Interventions

•Wound Care Protocols

–Skin tears

•Partial or Full thickness skin loss damage from traumatic injury separating the layers of skin.

–Nursing Care:

vDraining: Clean with Saf-Clenz wound cleanser, pat dry with 4 X 4 gauze, replace epidermal flap if able. Use steri strips to to hold in place if needed. Cover with Combiderm. Change Combiderm Q 1-2 X/wk and PRN dislodgement.

vNon-draining: Clean with Saf-Clenz wound cleanser, pat dry with 4 X 4 gauze, replace epidermal flap if able. Use steri strips to to hold in place if needed. May cover with petroleum gauze then secure with roll gauze, xeroform gauze then secure with roll gauze, transparent film, or leave open to air depending on area, size, and extent of wound. If using transparent film, do not remove until dislodged.

vDocumentation

Skin Integrity Interventions

•Wound Care Protocols

–Venous leg ulcers

•Assess extremity for arterial circulation. Determine if patient has had a doppler study, vascular assessment, or ABI within the last year.

•Assess wound and periwound for s/sx of infection. [If present notify MD].

•Wound Care protocols

–Neuropathic/Diabetic Ulcers

•Nursing Care

–Treat wound based on thickness of wound [partial or full] using wound care protocols.

–Consider growth factors {Regranex} for chronic, refractory wounds.

–Xeroform gauze has been shown to reduce bioburden in diabetic foot ulcers when kept moist. Change daily, cover with roll gauze.

–Assess for s/sx of infection to include osteomyelitis.

–Either bed rest or offloading bandaging is encouraged for plantar ulcers.

–Patient education re: footwear, tight glucose control, comorbidities, etc.

•Wound Care protocols

–Arterial Ulcers-ischemic ulcers resulting from lack of arterial circulation. Appear as shallow, well defined, ‘punched out’ areas with pale or necrotic base typically with minimal exudate on the distal aspect of limb or areas of trauma or friction.

•Nursing Care

–Wound care should be performed daily to provide frequent assessment and early detection of infection or deterioration.

–Treat wound based on thickness of wound [partial or full] using wound care protocols. Do not use occlusive dressing in arterial disease. Do not use H2O2 as topical therapy (cytotoxic, risk of air embolism).

–Light compression may be used 20-23mm/hg or pneumatic compression for thirty minutes 2-3 X day.