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 doesnt even do assessments on wounds yet. Modify and use any way you want, I wasnt 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 3rd 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.
Suggested Product formulary
Current
Combiderm
Aquacel
Aloe vesta
Xeroform
Petroleum gauze
Packing strips plain(Nu-gauze)
Transparent films
Saf-Clenz
Additions
Mesalt (debrider for wet wounds)
Hypergel (debrider for dry eschar, necrotic wounds)
Hydrogel for packing dry wounds, tunnels
3 layer compression