Wound Standing Orders:
1. Cleanse wounds with normal saline/wound cleansing spray/tap water with each dressing change.
2. Apply wound gel, cover with telfa, change daily.
3. Apply hydrocolloid dressing. Change every 3 days and prn soilage, wrinkles, leakage.
4. Apply gauze impregnated gel dressing daily, cover with telfa.
5. Apply hydrogel sheet. Change every 3 days and prn soilage, wrinkles or leakage.
6. Apply hydrofiber/alginate, cover with gauze or foam dressing. Change when drainage strikes through cover dressing.
7. Apply foam dressing over wound, change prn when drainage strikes through dressing.
8. Apply compression therapy weekly to treat venous stasis ulcers if ABI is greater than 0.8. Change PRN if large amount of drainage.
9. Enzymatic debrider to wound daily or BID, cover with moist gauze. ET nurse may cross hatch eschar as needed to allow enzyme penetration.
10. Wound dressing emulsion daily or BID to wound, cover with telfa.
11. Assess and place specialty bed/mattress for pressure relief/pressure reduction, prn.
12. Discontinue specialty bed/mattress when appropriate
13. Apply granulex spray TID to coccyx/reddened or open area with gentle massage.
14. Anti-microbial cream/powder to rash BID.
15. Topical antibiotics daily or BID to open skin tears and ulcers, cover with telfa.
16. ET may refer to PT for seating device or consultation regarding proper transfers.
17. ET to debride loose nonvascular non-viable slough/eschar in ulcer/wound base with blade/scissors.
18. May measure for and order knee-hi compression stocking initially 20-30 mmHg in treatment of venous stasis.
19. May measure for circaid compression therapy or legs.
18. Foot and Nail Team to evaluate and cut nails as necessary.
MD Signature _________________________________________ Date __________________