What are the orders for wound care management for a patient with wound changes until the next visit?

Home Health Nurse Wound Care Orders

The home health nurse should perform daily monitoring of the wound site, keeping it clean and dry using aseptic wound care techniques until the stoma tract is fully formed (usually 5-7 days post-procedure), then reduce dressing changes to 1-2 times weekly once healing occurs. 1

Initial Assessment and Monitoring

• Monitor the wound site daily for signs of bleeding, pain, erythema, induration, leakage, and inflammation 1
• Cleanse the wound to remove debris using 0.9% sodium chloride, sterile water, or freshly boiled and cooled water 1
• Document wound characteristics including size, depth, appearance, drainage, and surrounding tissue condition 2

Wound Dressing Protocol

For Fresh Wounds (First Week)

• Apply a sterile Y dressing under the external disc plate, followed by a skin-friendly, solvent-free breathable dressing 1
• Avoid occlusive dressings as they promote moisture and can lead to skin maceration 1
• Consider using a glycerin hydrogel or glycogel dressing as an alternative to classical aseptic wound care, which has shown significant reduction in infection scores 1
• Avoid applying tension when placing dressing under exterior bumper 1

After Initial Healing (After First Week)

• Reduce dressing changes to once or twice weekly 1
• Cleanse the entry site using soap and water of drinking quality 1
• Alternatively, dressings can be omitted and the site can be left open once properly healed 1

Wound Care Principles

• Follow the five basic principles of wound treatment 1:
  • Offload pressure from plantar ulcerations
  • Debride necrotic, nonviable tissue
  • Revascularize ischemic wounds when necessary
  • Manage infection (soft tissue or bone)
  • Use physiologic, topical dressings

Tube Management (If Applicable)

• Once the stoma tract has healed (after about one week), rotate the tube daily 1
• Move the tube inwards at least once weekly (at least 2 cm, up to 10 cm) to prevent buried bumper syndrome 1
• If the device is a gastrojejunostomy or gastrostomy with jejunal extension, do not rotate it (only push in and out weekly) 1

Infection Prevention

• For peristomal leakage of gastric contents, protect surrounding skin using zinc oxide-based skin protectants 1
• Monitor for signs of infection: increasing pain, redness, swelling, warmth, or purulent discharge 1, 3
• Obtain appropriate wound specimens for culture before initiating antibiotics if infection is suspected 1
• Cleanse and debride the lesion before obtaining specimens for culture 1

Follow-up Instructions

• Contact physician immediately for signs of infection, significant wound deterioration, or complications 1
• If wound fails to show reduction of 50% or more after 4 weeks of appropriate wound management, consider advanced wound therapy 1
• Document all wound care procedures, wound characteristics, and patient response to treatment 2

Special Considerations

• Avoid using negative pressure wound therapy following orthopedic surgery until safety in this population is established 1
• Consider patient preferences and relative benefits when selecting dressing types 1
• For patients with diabetes, ensure proper offloading and more frequent monitoring 1