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GENERAL WOUND AND SKIN CARE GUIDELINES
The following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity.
1. Perform agency’s pressure ulcer risk assessment on admission and PRN.
2. Wash hands before and after patient contact. Observe standard precautions.
3. Evaluate support surface need for bed/chair.
4. Teach patient/caregiver to turn/reposition accord ing to individualized repositioning schedule. Instruct other interventions to prevent pressure ulcers.
5. Teach patient/caregiver to perform incontinence care every AM and PRN.
6. Teach patient/caregiver wound management inter- ventions (i.e., dressing changes, signs and symp- toms of wound infection, etc.).
7. Perform agency’s nutritional assessment and make nutritional support interventions as needed. Encourage fluids unless contraindicated.
8. Dress chronic wounds using clean technique, since all chronic wounds are contaminated.
9. Cleanse wounds using a nontoxic agent (Dermal Wound Cleanser) or normal saline per MD order prior to making wound assessment and applying a new dressing.
10. Select a dressing that keeps the wound bed moist and the periwound skin dry.
11. Select a dressing that is at least 1 inch larger than the affected area.
12. Prepare the periwound skin with a skin sealant (Skin-Prep), prior to the application of any adhesive dressing or tape.
13. Perform the wound treatment. Picture frame dress- ings, as needed with tape, PRN.
14. Reevaluate dressing selection and skin integrity with every dressing change.
15. Reevaluate the wound’s response to the prescribed treatment. Make recommendations for changes PRN. Inform MD of changes in wound status.
16. Know the indications and contraindications for the wound products used.
17. Date, time, and initial all dressings at times of application.
18. Use care when removing all dressings and tapes. Use adhesive removers PRN.
19. Document wound assessment, treatment performed, and response to treatment on the appropriate docu- mentation form.
20. Contact members of your wound and skin care team and/ or wound care consultant if you have any questions.
Source: Alexian Brothers Medical Center Home Health Department, Hanover Park, IL.