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 topicallyBID

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: Silvadenecream(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 strengthto moisten gauze and apply topicallydaily. 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:______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

*1-21265* FORM 1-21265 REV. 02/2017 Page 1 of 1

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