- Venous ulcers
- Arterial ulcers
- Incontinence associated dermatitis
- Skin tears
- Neuropathic ulcers
- Pyoderma gangrenosum, cancers, vasculitides, and other dermatologic conditions
- Mobility impairment
- Reduced perfusion
- Sensory impairement
- Medical devices
Investigation –RBS , rule out osteomyelitis Xray , infection FBE , CRP , ABI, Monophillement , no superficial culture value
Comprehensive initial assessment of patient —manage underline issues eg Diabetes , PVD ,neuro
Wound assessment and treatment- TIME— hydrogel, hydrocolloid, foam , debridement
Assess goals of care and advance directives.
Refer – complex or nonhealing wounds, vascular surgery, drainage and/or débridement if advancing cellulitis, plastic surgery for skin graft/flap, dermatology referral if suspected pyoderma gangrenosum, cancer, vasculitis or other dermatologic conditions.