Wound Care

Wound Management, Products, and Support Surface Selection 313
— Appropriate lifting and positioning techniques
— Avoid use of soap to all dry skin areas. Lotion may be used
in bath water.
— Apply moisturizers BID to entire body
— Inspect and evaluate shoe gear for evidence of improper fit
Stage II:
• Inspection of all bony prominences during waking hours
every shift, twice daily, or more often
• Pressure reduction with turning schedule every 2 hours
• Heels off of mattress while in bed
• Foot cradle if ulcer is on foot/toe/heel
• NO massaging of the ulcer or periwound skin
• Instruct patient and family in basic skin care and repositioning
while in bed and while seated
• Appropriate lifting and positioning techniques
• Avoid use of soap to all dry skin areas. Lotion may be used in
bath water.
• Apply moisturizers BID to entire body
• Inspect/evaluate shoe gear for evidence of improper fit
• Evaluate nutritional and hydration status, change plan of care
as appropriate
• Ulcer treatment (NOT heel blisters):
• Cleanse gently with Normal Saline (NS)
• Cover with hydrocolloid, 3M Tegasorb®
• Appropriate application of any hydrocolloid requires that a
minimum of 1.0 cm of intact skin is at the wound edge is
under the dressing.
— Change every 3 to 5 days and prn leaking, peeling, or
contamination with incontinence.
• Heel blister treatment:
• If skin on heel is intact no dressing is necessary if heel is elevated
off mattress and leg is elevated when up in chair.
• If skin is open: