Wound Care – Cleansing / Skin Protectant
PATIENT CARE SERVICES
Department:
Patient Care Services
Procedure for:
Wound Cleansing/Skin Protectant
NOTE:
CALL PHYSICIAN FOR ORDERS TO BEGIN WOUND
ALGORITHM PROCEDURES.
PURPOSE:
To outline the management of wound cleansing and skin protection via
nonirritating wound cleansing formulation that gently remove bacteria and
surface contaminants without harming fragile wound tissue.
SUPPORTIVE DATA:
Wound cleansing care requires competent staff (advanced CNAs, LPTs,
ETs, LPNs, RNs) following procedures that ensure the removal of necrotic
tissue, exudate and metabolic waste from the wound bed to optimize the
potential for healing and reduce the chance for infection. There must be
protection of the healing wound bed. This cleansing and irrigation should
be done for acute and chronic wounds of all types.
EQUIPMENT LIST:
·
·
·
·
normal saline or wound cleanser/skin protectant (external use only)
soft cloth/gauze
gloves
towels/Chuxs®
CONTENT:
STEPS
1.
Identify and prepare patient for
procedures.
2.
Provide for privacy.
3.
Wash hands and put on gloves.
KEY POINTS
Patient Care Services
Procedure for Wound Cleansing/Skin Protectant
Page 2
4.
Assess the wound for cleansing,
removal of debris/odor and reduction of
trauma associated with mechanical
scrubbing.
Cleaning with wound cleanser will not
disrupt the natural healing process and
surfactant formulation lowers surface
tension to minimize trauma to wound.
5.
Assemble equipment and place on
protective barrier at bedside.
Use of protective barrier under equipment
provides for protection of environmental
surfaces.
6.
Position patient so that affected area is
exposed. Place protective Chuxs®
under patient.
7.
Apply wound cleanser/skin protectant to
create a direct stream or mist on
affected area. Gently blot off with
gauze to remove any debris.
Trigger or direct spray provide psi to
assist with removal of debris and odor
without disrupting wound bed.
8.
Apply liberally to entire affected area as
needed.
pH balanced and contains no detergents;
no rinsing required.
9.
Repeat as often as necessary.
Agents reduce bacterial contamination
and helps control infection. Provides an
alternative to harsh antiseptic solutions,
e.g., Dakin’s, hydrogen peroxide,
povidone iodine.
10.
Document procedure including
wound/skin assessment before and after.
Also, describe patients’ tolerance and
any difficulties encountered.
Glossary of Terms:
Terms
denuded
erosion
erythema
excoriation
induration
maceration
Definition
loss of epidermis
loss of epidermis
redness of the skin surface
linear scratches on the
skin
abnormal firmness of
tissue
softening of tissue by
soaking in fluids
Patient Care Services
Procedure for Wound Cleansing/Skin Protectant
Page 3
REFERENCES:
Treating Pressure Sores, Clinical Practice Guidelines, US Department of
Health & Human Services, 1994.
Restore Clean ‘N Moist Skin Protectant, Hollister Incorp., 1997.
Restore Calcicare Dressings, Hollister Incorporated, 1997.
Hydrogel Wound Dressings, Hollister Incorporated, 1997.
Wound and Skin Care, Hollister Incorporated, 1997.
Nurse’s Clinical Guide Wound Care, 2nd edition, Cathy Thomas Hess, RN,
BSN, CETN, Springhouse Corporation, 1998.
Wound Care Patient Education Resource Manual, Carrie Sussan, An
Aspen Publication, 1999.
Wound Care - Clinical Practice Guidelines, U.S. Department of Health
and Human Services, 1999.
APPROVAL:
Standards Development Committee
May2000
Wound Care Team
May 2000
DISTRIBUTION:
All nursing units