IMPAIRED SKIN / SIMPLE WOUND MANAGEMENT PROTOCOL
 All MD orders supersede these protocols
 Initiate Protocol for Increased Skin Risk
 Initiate care as follows, even if WOC consult has been placed
Skin Tear with
Viable Flap Attached
Skin Tear with Flap Removed
Dry Skin Tear with Scab
Skin Tear with Signs of Infection
Skin Tear, Bleeding
 Cleanse with normal saline or wound cleanser
 Use cotton swab to push flap back in place
 Apply Steri-strips to secure flap in place
 Cover with foam dressing and secure with roll gauze or
Medipore tape if not on extremity
 Change every 4 days and PRN if drainage saturates
dressing
 If purulent drainage develops consult physician and/or
WOC nurse
**Note: If skin flap non-viable notify MD for debridment
of flap
 Cleanse with wound cleanser or normal saline
 Cover with silver foam dressing and secure with roll gauze
or Medipore tape if not on an extremity
 Change every 4 days and PRN if drainage saturates
dressing
 If purulent drainage develops consult physician and/or
WOC nurse
 Leave open to air, may cover with dry non-adherent
protective dressing and secure with roll gauze or Medipore
tape if not on an extremity
 Change every 5 days
 Cleanse with wound cleanser or normal saline
 Cover with normal saline moist dressing secure with roll
gauze or Medipore tape if not on an extremity
 Change every 12 hours and PRN if drainage saturates
dressing
 Consult physician and/or WOC nurse for further treatment
 Cleanse with wound cleanser or normal saline
 Apply calcium alginate to wound, cover with dry gauze and
secure with roll gauze or Medipore tape if not on an
extremitiy
 Change dressing in 2 days
 Saturate dressing with wound cleanser or normal saline
and remove gently
 If still bleeding, reapply calcium alginate as instructed
above.
 If no longer bleeding follow wound care under Skin Tear
Flap Removed

Epidermis Intact with
Nonblanchable Erythema
Stage II/Partial Thickness
Wound(s) with shallow depth,
pink/red wound base small
drainage and no stool
contamination
Stage II/Partial Thickness
Wound(s) with shallow depth,
small drainage and stool
contamination possible
Stage III / Full Thickness Shallow
Wounds with or without Slough,
Small Drainage
 Assess every shift and take measures to alleviate causative
factors if possible
 Implement Increased Skin Risk Protocol
 Apply moisture barrier creams every 8 hours if patient is
incontinent of urine or stool
 DO NOT massage reddened areas
 If more than one body surface involved, consult WOC
nurse and implement specialty bed evaluation
 Cleanse with wound cleanser or normal saline
 Cover wound with foam dressing and secure with
Medipore tape. Change every 3 days and PRN when
drainage saturates dressing OR
 Apply zinc oxide barrier cream and/or zinc oxide
impregnated gauze every 8 hours and PRN with routine
hygiene
**Note: Gently remove soiled layer of zinc oxide only,
then replace zinc oxide and /or zinc oxide
impregnated gauze.
 If more than one surface involved consult WOC nurse for
specialty bed evaluation
 If purulent drainage develops or ulcer worsens consult
physician and/or WOC nurse
 Cleanse wound with wound cleanser or normal saline
 Apply 4-6 strips of zinc oxide impregnated gauze to area
 Smooth down edges of zinc oxide impregnated roll gauze
to get good adherence of product to tissue
 Apply every 8 hours and after each incontinent episode
** Note: Gently remove soiled layer of zinc oxide only,
then replace zinc oxide impregnated gauze.
 If purulent drainage develops or ulcer worsens notify
physician and consult WOC
 Cleanse with wound cleanser or normal saline
 Apply normal saline moist dressing, cover with dry gauze
and secure with Medipore tape
 May add hydrogel to normal saline moist gauze if needing
to maintain moisture
 Change dressing every 12 hours and PRN when drainage
saturates dressing
 Place a WOC nurse consult and notify physician for further
treatment and specialty bed evaluation

Stage III /IV & Full Thickness
Deep/Crater/Tunneling Wounds
with Moderate/Large Drainage,
with or without Slough
Deep Tissue Injury (DTI)
Heel Protocol
Blisters Intact or Ruptured
Dry Crusted Skin to
Legs and/or Feet
 Cleanse wound with wound cleanser or normal saline
 Fill wound lightly with calcium alginate, cover with dry
gauze and secure with Medipore tape
**Note: Use plain strip gauze to wick any narrow
tunnels and calcium alginate rope for undermined areas
or wide tunnels.
 Change dressing daily and PRN when drainage saturates
dressing
 Place a WOC nurse consult and notify physician for further
treatment and specialty bed evaluation
 Place a Nutrition Consult
 Establish a turning schedule every 2 hours or more
frequently
 Apply zinc impregnated gauze (fan folded) to area
 Change every 8 hours and PRN when soiled
 DO NOT MASSAGE area of DTI
 Place WOC nurse consult and notify physician for further
treatment and specialty bed evaluation
 Assess Vascular Status to lower leg – pulses, temp and
color: If compromised vascular status
 Blister intact or Black Eschar paint with Betadine (if no
allergy to iodine), cover with dry gauze and secure with roll
gauze. Change daily
 If allergy noted to iodine, apply skin sealant wipes, cover
with dry gauze and secure with roll gauze. Change daily
 Blister ruptured apply fan folded zinc oxide roll gauze or
bismuth gauze, cover with dry gauze and secure with roll
gauze. Change daily
 Never apply hydrocolloids to heels
 Heel boots while in bed and as tolerated when up in chair
 Place WOC nurse consult and notify physician for further
treatment
 Wash daily with soap and water to help remove excess skin
 Apply moisturizing cream every 12 hours
 Do Not apply moisturizing cream between toes
 Apply socks to feet before getting out of bed

Perineal Dermatitis-Yeast
Rash Suspected with or without
Denuded skin
Incontinence Dermatitis
No Yeast Rash Suspected
with or without Denuded Skin
July 2012
 Cleanse area with wound cleanser or routine hygiene
products
 Avoid use of plastic underpads, use breathable underpads
 Avoid use of diapers if possible
 To Peri-areas: Apply antifungal barrier cream every 8
hours, may apply layer of zinc oxide impregnated gauze
over barrier cream if needed
 If yeast like rash to skin folds or beneath breast: Apply
2% Miconazole antifungal powder, apply to areas every 8
hours. May use dry gauze to area to wick away moisture
 If vaginal discharge present, notify physician and obtain
order for vaginal or systemic anti-fungal agents
 If yeast like rash extending beyond peri-areas, notify
physician and obtain order for systemic anti-fungal agents
 Place WOC consult if low air loss mattress recommended
 Cleanse with wound cleanser or routine hygiene
products
 Apply 4-6 strips of zinc oxide impregnated gauze to
area
 Smooth down edges of zinc oxide impregnated
gauze to get good adherence of product to tissue
 Apply every 8 hours and after each incontinent
episode
**Note: Gently remove soiled layer of zinc oxide
only, then replace zinc oxide impregnated
gauze
 If purulent drainage develops or ulcer worsens
notify physician and consult WOC