Wound Care - Hydrogel
PATIENT CARE SERVICES
Department:
Patient Care Services
Procedure for:
Hydrogel Dressing
NOTE:
CALL PHYSICIAN FOR ORDERS TO BEGIN WOUND
ALGORITHM PROCEDURES.
PURPOSE:
To outline the management of wound dressing with hydrogel product.
Hydrogel dressing rehydrates wounds, provides for atraumatic autolytic
debridement of wounds and reduces pain associated with the dressing
changes.
SUPPORTIVE DATA:
Hydrogel dressings are ideal for loose packing in deep nondraining
and/or infected wounds. Hydrogels come in a variety of forms to
facilitate clinical application. Hydrogel dressings have a viscous
formulation and provide for a moist wound interface for up to 72 hours.
The dressings require licensed physical therapist, ET, LPN and/or RN staff
that follow outline procedures.
EQUIPMENT LIST:
·
·
·
·
·
·
·
hydrogel dressing
normal saline or wound cleanser, as indicated, for wound cleansing
wound measuring guide
gauze or other dry material to dry surrounding skin
secondary cover dressing
gloves (two pair)
towels/Chux®
Patient Care Services
Procedure for Hydrogel Dressing
Page 2
CONTENT:
A.
PLACEMENT OF HYDROGEL DRESSING
STEPS
KEY POINTS
1.
Wash hands and put on gloves.
2.
Identify and prepare patient for
procedure.
3.
Provide for privacy.
4.
Assess the wound for appropriateness of
hydrogel dressing.
Ideal for loose packing in deep
nondraining wounds. Hydrogels fill in
dead space associated with sinus tracts,
undermining or deep wounds.
Hydrogel maintains a moist wound
environment for the healing of partial
to full thickness wounds.
5.
Assemble equipment and place at
bedside.
Use of protective barrier under equipment
provides for protection of environmental
surfaces.
6.
Wash hands and put on new gloves.
7.
Thoroughly rinse or irrigate the wound
area with normal saline or wound
cleanser if appropriate (if necessary, the
wound should be debrided).
See wound cleansing/skin protectant in
Generic Structure Standards.
8.
Clean and dry the surrounding skin to
allow for secure adhesion of the
secondary dressing.
Hydrogel dressings may cause maceration
if allowed to remain in contact with
healthy periwound skin.
Position patient so wound area is exposed
and remove dressing if present. Place
protective Chux® under patient.
Patient Care Services
Procedure for Hydrogel Dressing
Page 3
9.
Measure the wound using the wound
guide.
Hydrogel is available in a variety of forms
(amorphous, impregnated gauze pads
and strips).10. Cover or pack wounds
with hydrogel sponge, strip, gauze or
tube gel.
Hydrogel dressings should not overlap on
surrounding periwound skin. Apply
hydrogel dressings to a minimum depth
of 5 mm (1/4").
11.
Cover hydrogel dressing with an
appropriate secondary dressing and
secure.
Secondary dressing should not be
absorptive, i.e., hydrocolloid forms or
alginates.
12.
Document assessment of wound before
and after wound cleansing and dressing
change.
Key observations:
size
extent of tissue involvement (partial or
full thickness)
presence of undermining or tracts
anatomic location
wound base (granulation, muscle,
subcutaneous tissue, nonviable
tissue, color, exudate
amount/odor/color)
edges of wound
presence of foreign bodies
condition of surrounding skin
duration of wound
B.
REMOVAL OF HYDROGEL DRESSING
1.
Wash hands and put on gloves.
2.
Identify and prepare patient for
procedure.
3.
Provide for privacy.
Position patient so wound area is exposed
and remove dressing if present. Place
protective Chux® under patient.
Patient Care Services
Procedure for Hydrogel Dressing
Page 4
4.
Assemble equipment needed for
removal of old dressing and
placement of new.
Use of protective barrier under equipment
provides for protection of
environmental surfaces.5.
Remove secondary dressing
and discard appropriately.
6.
Remove hydrogel dressing from
wound bed.. Irrigate remaining
hydrogel dressing from wound bed
using normal saline or wound
cleanser.
The dressing can be left in place up to 72
hours, if wound cleanser is applied. When
more frequent dressing changes are
performed, normal saline is adequate as a
cleanser.
7.
Change gloves and wash hands.
8.
Reassess wound for new dressing
needs and change as ordered/needed.
Discontinue hydrogel dressing if wound
develops moderate amounts of exudate. If
no progress can be demonstrated within 2-4
weeks, reevaluate the overall treatment plan
as well as adherence to this plan, making
modification as necessary.
9.
Document assessment of wound
before and after cleansing and
dressing change.
Key observations:
size
extent of tissue involvement (partial or
full thickness)
presence of undermining or tracts
anatomic location
wound base (granulation, muscle,
subcutaneous tissue, nonviable
tissue, color, exudate
amount/odor/color)
edges of wound
presence of foreign bodies
condition of surrounding skin
duration of wound
Patient Care Services
Procedure for Hydrogel Dressing
Page 5
REFERENCES:
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
May 2000
Wound Care Team
May 2000
DISTRIBUTION:
All nursing units