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The following information is designed as a guideline for care. Consult with a wound care specialist and/or physician with questions and when managing full-thickness and infected wounds.
- Minimize or eliminate the cause of the problem. Proper turning, transferring and positioning techniques, support surfaces for bed or chair as indicated by level of risk. With heel/foot ulcers, provide appropriate pressure relief and orthotics as needed.
- Support moist wound healing.
- Treat infection. Consult with physician to determine need for antibiotic therapy, debridement, cleansing, and dressing approach.
- Debride. This is based upon condition of the wound and the patient. Methods of debridement include autolytic, mechanical, sharp, and enzymatic.
- Protect the wound from external contamination. (e.g., fecal matter, urine, microorganisms) and trauma
- Perform daily skin inspection and care. This may include cleansing, moisturizing, and the use of protective barriers.
- Provide adequate nutritional intake.
- Manage pain.
- Provide education to patient, family, and caregiver.
- Document assessments and interventions.
- Reassess at regular intervals per agency protocol.
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