| Information for health care professionals click on brain to return to index page |
 |
| Neuroland |
| Neuro Med |
| Neuro Note |
| Practice hint |
| Relax page |
| PubMed |
| DNS |
| Skin Care Protocol | ||||
| at risk | Stage I | Stage II | Stage III & IV | |
| Criteria | incontinent or other risk factors | redness, intact skin | Partial thickness skin loss | Full thickness skin loss or wound with necrotic tissue |
| Consults | Nutrition | Nutrition | Nutrition, PT, skin care nurse | |
| General care | Turning /positioning q2 hour | |||
| Bath with Keri Oil and condition with Lubriderm bid | ||||
| pressure reduction mattress | specialty bed | |||
| Dressing/ treatment | none | Tegaderm or Comfeel Transparent Hydrocolloid dressing to protect skin integrity | Comfeel Transparent Hydrocolloid if non draining, Duoderm or Allevyn Adhesive dressing if draining, NuGel for burns or lightly draining wounds | Saline moistened gauze packing bid for draining wound (Mirasorb, Kerlix, Kling), Duoderm dressing for black eschar |
| Perineal care for incontinent patient | Triple care cleanser & protective cream bid and prn | Clean with water and apply TRIAD every shift and prn | ||
| Culture | usually not indicated | if redness, fever, swelling, elevated WBC, odorous drainage | ||
