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SKIN CARE//WOUND CARE ALGORITHM

INTACT SKIN SPECIAL CONSIDERATIONS GUIDELINES FOR OPEN WOUNDS

Assessment red skin-redness lasts longer than 30 minutes after pressure is relieved do not massage over reddened pressure areas Protective Covering *Duoderm *Mepilex

Intact blister Purple/Bruised Skin * Mepitel and Mepilex *close observation Open Blister *protect * Mepitel & Mepilex or * Safe gel & Mepilex Stable eschar hands & feet: no drainage * Paint with Betadine * Wrap hands and feet with Kerlix for protection * If draining send WOCN Consult

NOTE: Change dressings per WOCN /MD order or when dressing is visibly saturated. Always document in Nurses Note. Duoderm Signal or Duoderm thin page may be used1interchangeably

Occipital or Scrotum Care * For dry ulcers use duoderm thin * For moist ulcers use Aquacel Ag and Duoderm thin

Cleansing normal saline Assessment color, drainage, odor location, depth, size use filler dressing in cavities and the appropriate cover dressing as needed Fillers and Covers Depth and Drainage

Care of Skin Tears *Clean tear with NS *Approximate tear *If Skin Tear is dry use * NS and Kerlix or * Mepilex, Safe Gel , Mepitel * Change weekly If Skin Tear is draining *Send WOCN consult

NOTE: C WOCN /M dressing Always d Note.

Duoderm thin may changea

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SKIN CARE//WOUND CARE ALGORITHM

Skin Care Product Choices Care of Dry Skin * Apply one of the following products * After baths on heels, elbows,& feet * Do not put in between toes * Sensicare 2 * Lubriderm (Non greasy) Accudose override * Eucerin -Accudose override- skin impaired by dx: Diabetes enhances absorption of topical meds * Sween Cream- found in Accudose Care of Skin Affected by Urinary Incontinence/ Minimal Stools * Sween Cream (Accudose) apply after each incontinent episode * Aloe Vesta- Apply after each incontinent episode Care of Skin Affected by Diarrhea * Sensicare Protective Barrier Cream 3 * Apply cream liberally-do not rub in or off * Only wipe off top layer when removing * Use if skin is broken, denuded * Used to protect perineal skin around Stage 1 or 2 Protection of Heels/ Elbows *Mepilex heel protectors *Tubifast covering Deep/Wet Wounds (moderate-large drainage) Filler choices Cover choices *Kerlix *ABD pad *4x4's *Mepilex *Kling *Coverderm *Combiderm *Versiva Deep/Dry Wounds (minimal or no drainage) Filler choices *normal saline moist gauze *Saf-gel with moist gauze *Silva Sorb gel w/moist gauze *use Kerlix, Kling or 4x4's *Aquacel - moisten *Aquacel ag - moisten Cover choices *Coverderm *Versiva *Combiderm *ABD pad *Mepilex

Shallow/Wet Wounds (moderate/large drainage) Filler choices Cover choices *Kerlix *Mepilex *ABD pad *4x4's *Coverderm *Combiderm *Kling *Versiva *Aquacel *Aquacel ag

Shallow/Dry Wounds (minimal or no drainage) Filler choices *normal saline moist gauze *Saf-gel moist gauze *Silva Sorb gel moist gauze *(use Kerlix,Kling or 4x4's) *Aquacel - moisten *Aquacel ag - moisten Cover choices *Mepilex *Coverderm *ABD pad

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Revised April 2008

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