MENDOCINO COAST DISTRICT HOSPITAL
GENERAL PATIENT CARE POLICY AND PROCEDURE STATEMENT
NUMBER: 205.1260
PAGE: 3 OF 3
TITLE: DRESSINGS; HYDROCOLLOID
PURPOSE:
To provide a means of wound care that reflects current concepts and principles of wound management. To promote wound epithelization and granulation through auto-debridement. To simplify wound management and reduce manipulation of the wound.
PRODUCT EXAMPLES:
Convatec: DuoDerm CGF wafers & Extra Thin,
Hollister: Restore; Coloplast: Comfeel and Comfeel Transparent
INDICATIONS:
Prevention and management of pressure ulcer and leg ulcers, minor abrasions, second degree burns. Scant to small drainage. May be used to soften eschar.
CONTRAINDICATIONS:
Presence of active infection. Heavily draining wound – use cautiously in-patient with fragile skin.
EQUIPMENT:
· NS; hydrocolloid dressing
· Gloves
· Skin Barrier Wipes and tape pin
PROCEDURE:
When occlusive dressings are used in the presence of necrotic material, expect to see an increase in size and depth during the initial healing phases as necrotic debris is cleared away.
1. Obtain MD order.
2. Wash hands, don gloves.
3. Gather Equipment.
4. Cleanse wound and surrounding area with saline and gauze to remove debris and necrotic tissue.
Note: Skin must be clean and free of any ointments, creams, solvents, and moisture.
5. Prepare hydrocolloid dressing. – Allow for a 1 ¼” margin beyond the wound. Date and initial dressing.
Note: Edges of the dressing may be “feathered” with scissors to assist contoured application.
6. Apply skin barrier film around ulcer, extending out beyond border of hydrocolloid prn to protect fragile skin.
7. Remove the paper backing from the dressing, minimizing finger contact with adhesive surface.
8. Apply dressing directly over the wound with a rolling motion. Do not stretch the dressing.
9. Smooth gently, but firmly into place.
Note: Dressing adhesion improves as the dressing becomes warm. When applying dressing to gluteal fold; skin folds; or concave areas: orient the dressing so a corner is placed well down into the gluteal fold; push into the hollow and press firmly for several seconds to enhance adhesion. Dressing may be custom cut.
10. May “picture frame” the dressing with tape. This secures the seal, prevents edges from curling and peeling.
Note¹: Some wrinkling may occur in the dressing. This is normal and should not be the cause for dressing removal.
Note²: Hydrocolloid dressings are impermeable to fluids, so the patient may bathe or shower. This proves advantageous with the incontinent patient as well.
11. Chart wound assessment and dressing application in the patient medical record.
12. Notify MD of significant findings.
13. Teach patient/caregiver, as appropriate.
14. Follow infection control and OSHA bloodborne pathogen guidelines, as appropriate.
REMOVAL OF THE HYDROCOLLOID DRESSING
1. Hydrocolloid dressings are designed to remain in place up to seven (7) days. Change is required prior to this when:
· Patient complains of discomfort
· Oozing, leaking occurs
· Clinical signs of infection area present
· Dressing is bunched up or no longer intact.
· Wash hands.
· Don gloves.
· Remove tape.
2. Carefully lift an edge of the dressing while stabilizing the skin with pressure. Continue slowly around the margins of the dressing until all edges are freed from skin surface. Lift carefully from wound.
Note: Hydrocolloid dressings interact with wound exudates producing a soft moist gel at the wound surface and on the dressing. Due to the color of the product, this may have the appearance of pus. This is normal. The wound requires cleansing before you can accurately evaluate. Occlusive dressings, particularly those over large or necrotic wounds, may accumulate odor. With leakage or dressing removal, the odor may be pronounced. Assess after cleaning.
3. Dispose of dressing per hospital policy.
4. Gently cleanse the wound of any accumulated gel or debris.
5. Assess the wound.
6. Reapply dressing
7. Document in nursing electronic medical record per hospital policy.
8. Secure with tape as needed
9. Teach patient/caregiver, as appropriate.
10. Follow infection control and OSHA bloodborne pathogen guidelines, as appropriate.
Note: In some patients, it’s appropriate to continue use of hydrocolloid dressings for 1 – 2 weeks after apparent healing, to protect fragile new tissue and prevent re-injury.
New: Revised:
Approval Signatures:
Signature on File
Nurse Manager Date
Signature on File
Chief Clinical Officer Date
Signature on File
Medical Chief of Staff Date
Signature on File
Chief Executive Officer Date
Signature on File
President, Board of Directors Date