Wound Care Plan

Ischaemic Leg tissue – Debrided

Last Updated
19 May 2025
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Quick Overview

Reference ID Number: TWS-WCP-27

Categories

Ischaemic Areas

Scope of Practice (ScOP) Designation

Registered Nurse (RN),Enrolled Nurse (EN),Medical Officer

Treatment Goals

Remove bacterial load on wound bed that is hindering granulation tissue growing. And in this case that destroyed a split skin graft do to heavy exudate.

Aim of Dressing

Reduce the bacterial burden on the wound bed and provide a moist wound healing environment that still allows for physiotherapy to be participated in.

Frequency of Dressing Change

Everyday

References

Shopping List

Dressing Pack (Large),Normal Saline,Sterile Gloves (Size 7.5),Acetic Acid (5%),Kerlix (11.4cm x 3.7m),Zetuvit Plus (15cm x 20cm),Hypafix (5cm x 10m)
Page Table of Contents

    Product Selection Disclaimer:

    The wound care products being currently used are a suggestion ONLY. They do not take into account your patient's individual needs which you must assess. No funding from medical companies has been provided and wound care products are chosen on their merit and what is available on the NSW Health State Wound Care Contract. Where an exact brand name product is not available we suggest you review the alternative tab or use another wound care product from its category eg. Hydrofibre

    Photo Gallery

    Care Plans

    Betadine packing

    Where vac-ing isn't possible or pseudomonas is present daily dressings can be used till the wound is ready for a vac and the pseudomonas has been controlled

     Swipe 
    Step 1

    Prepare Sterile Field

    Prepare your sterile field with your sterile products
    Products Used
    Step 2

    Clean wound bed

    Clean the wound bed thoroughly removing any slough, devitalised tissue (in this case the black area) and make sure you get into the crevasses)
    Products Used
    Step 3

    Apply acetic acid gauze

    Soak the kerlix in acetic acid. Try and not ring it out too much. It is VERY important that you cover all the exposed wound bed and push the kerlix into crevasses. Before you cover push the dressing down making sure there is great contact between the kerlix and the wound bed.
    Products Used
    Step 4

    WAIT 11 minutes

    Wait. Do not rush this part. Go write a note, give an antibiotic BUT do not rush this part. Or you could youtube a Sponge bob SquarePants episode.
    Products Used
    Step 5

    Remove the acetic acid

    Remove the acetic acid soaked kerlix. You do not need to do anything to the wound bed.
    Products Used
    Step 6

    Apply Betadine soaked gauze

    Soak the kerlix in betadine and then layer over the wound bed in the same fashion as the acetic soak.
    Products Used
    Step 7

    Secure

    Secure with zetuvit and hypafix
    Products Used
    Step 8

    Smell the chips

    Now you know that acetic acid is the same as the vinegar you love on salt and vinegar chips
    Products Used

    Vac-ing

    Where possible a vac should be applied to allow rapid growth of granulation tissue to occur. In this patient's case it also helped facilitate her physiotherapy as she found it easier to mobilise with the vac than the simple packing.

     Swipe 
    Step 1

    Prepare Sterile Field

    Prepare your sterile field with your sterile products
    Products Used
    Step 2

    Clean wound bed

    Clean the wound bed thoroughly removing any slough, devitalised tissue (in this case the black area) and make sure you get into the crevasses)
    Products Used
    Step 3

    Vac the wound

    Fill the cavity with the foam making sure you get the foam into any crevasses
    Products Used
    Additional : Step 5

    Alternative

    You could use a bridge dressing if the wound is on the back of the thigh muscle
    Products Used