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Most severe wound infections, and moderate infections in high-risk patients, require initial parenteral antibiotics, with transition to oral antibiotics after therapeutic response. The diagnosis is based on clinical evaluation. Learn the Signs, Overview of Purpuric Rash, a Symptom of Some Conditions, Debra Sullivan, Ph.D., MSN, R.N., CNE, COI, How to Get Rid of Dark Circles Permanently. U[^Y.!JEMI5jI%fb]!5=oX)>(Llwp6Y!Z,n3y8 gwAlsQrsH3"YLa5 5oS)hX/,e dhrdTi+? Topical antibiotic ointments decrease the risk of infection in minor contaminated wounds. 2005-2023 Healthline Media a Red Ventures Company. The most reliable way to remove a cyst is to have your doctor do it. Mayo Clinic Staff. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Make the incision. Change the dressing if it becomes soaked with blood or pus. In one prospective study, beta-hemolytic streptococcus was found to cause nearly three-fourths of cases of diffuse cellulitis.16 S. aureus, P. aeruginosa, enterococcus, and Escherichia coli are the predominant organisms isolated from hospitalized patients with SSTIs.17 MRSA infections are characterized by liquefaction of infected tissue and abscess formation; the resulting increase in tissue tension causes ischemia and overlying skin necrosis. All rights reserved. This information is not intended as a substitute for professional medical care. Your doctor will treat an MRSA abscess the same as another similar abscess by draining it and prescribing an appropriate antibiotic. Preauricular abscess drainage without Incision: No Incision-Dr D K Gupta. The gauze dressing on the skin over the wound incision may need to be in place for a couple of days or a week for an abscess that was especially large or deep. 2021 Jul 27;13:335-341. doi: 10.2147/OAEM.S317713. 13120 Biscayne Blvd., North Miami 305-585-9210 Schedule an Appointment. Laboratory testing may be required to confirm an uncertain diagnosis, evaluate for deep infections or sepsis, determine the need for inpatient care, and evaluate and treat comorbidities. If a gauze packing was put in your wound, it should be removed in 1 to 2 days, or as directed. Often, this is performed in an operating theatre setting; however, this may lead to high treatment costs due to theatre access issues or unnecessary postoperative stay. This, and sometimes a course of antibiotics, is really all thats involved. Five RCTs with a total of 159 patients found weak evidence that enzymatic debridement leads to faster results compared with saline-soaked dressings.34 Elevation of the affected area and optimal treatment of underlying predisposing conditions (e.g., diabetes mellitus) will help the healing process.30, Antibiotic Selection. Treatment of necrotizing fasciitis involves early recognition and surgical consultation for debridement of necrotic tissue combined with empiric high-dose intravenous broad-spectrum antibiotics.5 The antibiotic spectrum can be narrowed once the infecting microbes are identified and susceptibility testing results are available. The abscess is left open but covered with a wound dressing to absorb any more pus that is produced initially after the procedure. 15,22,23 The addition of systemic antibiotic therapy is recommended if the patient has signs and symptoms of illness, rapid progression, failure to respond to incision and drainage alone, associated comorbidities or immunosuppression, abscess in . Healing could take a week or two, depending on the size of the abscess. Posted in Cyst Popping Tagged abscess drainage procedure., abscess drainage videos, abscess healing stages, care after abscess incision and drainage, hard lump after abscess drained, how to drain abscess at home, how to tell if abscess is healing, what to expect after abscess drainage Leave a Comment on Inflamed Abscess Drainage Post . If a gauze packing was placed inside the abscess pocket, you may be told to remove it yourself. Abscess Drainage. The wound may drain for the first 2 days. Rhle A, Oehme F, Brnert K, Fourie L, Babst R, Link BC, Metzger J, Beeres FJ. Appointments 216.444.5725. One solution is to perform abscess drainage as a day- Mohamedahmed AYY, Zaman S, Stonelake S, Ahmad AN, Datta U, Hajibandeh S, Hajibandeh S. Langenbecks Arch Surg. Most simple abscesses can be diagnosed upon clinical examination and safely be managed in the ambulatory office with incision and drainage. (2018). Suturing, if required, can be completed up to 24 hours after the trauma occurs, depending on the wound site. However, if the infection wasnt eliminated, the abscess could reform in the same spot or elsewhere. -----View Our. Author disclosure: No relevant financial affiliations. Incision and drainage of abscesses in a healthy host may be the only therapeutic approach necessary. Randomized Controlled Trial of a Novel Silicone Device for the Packing of Cutaneous Abscesses in the Emergency Department: A Pilot Study. Perianal abscess requires formal incision of the abscess to allow drainage of the pus. The American Burn Association has created criteria to help determine when referral is recommended (available at https://www.aafp.org/afp/2012/0101/p25.html#afp20120101p25-t4).29. Also get the facts on causes and risk, Boils are painful skin bumps that are caused by bacteria. An abscess can happen with an insect bite, ingrown hair, blocked oil gland, pimple, cyst, or puncture wound. Perianal Abscess. Older age, cardiopulmonary or hepatorenal disease, diabetes mellitus, debility, immunosenescence or immunocompromise, obesity, peripheral arteriovenous or lymphatic insufficiency, and trauma are among the risk factors for SSTIs (Table 2).911 Outbreaks are more common among military personnel during overseas deployment and athletes participating in close-contact sports.12,13 Community-acquired MRSA causes infection in a wide variety of hosts, from healthy children and young adults to persons with comorbidities, health care professionals, and persons living in close quarters. Abscess Drainage - For Patients . The area around your abscess has red streaks or is warm and painful. It is not intended as medical advice for individual conditions or treatments. The observational studies demonstrated mixed results regarding rates of treatment cure with appropriate antibiotic selection, specifically in patients with positive wound cultures for MRSA. stream You see pus (which is usually a sign of infection). This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. It offers faster recovery than open surgical drainage. You may do this in the shower. Post-Operative Instructions after Incision And Drainage of a Dental Infection (Abscess) - 2 - What medications do I need to take? Change the dressing if it becomes soaked with blood or pus. About 10% to 30% of all breast abscesses occur after pregnancy, when nursing mothers breastfeed newborns. You can expect a little pus drainage for a day or two after the procedure. What kind of doctor drains abscess? JMIR Res Protoc. Cover the wound with a clean dry dressing. The primary way to treat an abscess is via incision and drainage. Please see our Nondiscrimination For example: an abscess of the eyelid should be billed with procedure code 67700 (Blepharotomy, drainage of abscess, eyelid); a perirectal abscess should be billed with procedure code 46040 (Incision and drainage of ischiorectal and/or perirectal abscess . Copyright 2015 by the American Academy of Family Physicians. 2000-2022 The StayWell Company, LLC. Write down your questions so you remember to ask them during your visits. The skin around the abscess may look red and feel tender and warm. Bookshelf Its usually triggered by a bacterial infection. See permissionsforcopyrightquestions and/or permission requests. Due to limited studies and conflicting data, we are unable to make a recommendation in support or opposition of adjunctive post-procedural packing and antibiotics in an immunocompromised patient. It happens when bacteria get trapped under the skin and start to grow. An RCT of 426 patients with uncomplicated wounds found significantly lower infection rates with topical bacitracin, neomycin/bacitracin/polymyxin B, or silver sulfadiazine (Silvadene) compared with topical petrolatum (5.5%, 4.5%, 12.1%, and 17.6%, respectively).22, Topical silver-containing ointments and dressings have been used to prevent wound infections. and transmitted securely. Incision and drainage after care? Diagnostic testing should be performed early to identify the causative organism and evaluate the extent of involvement, and antibiotic therapy should be commenced to cover possible pathogens, including atypical organisms that can cause serious infections (e.g., resistant gram-negative bacteria, anaerobes, fungi).5, Specific types of SSTIs may result from identifiable exposures. Simple infection with no systemic signs or symptoms indicating spread, Infection with systemic signs or symptoms indicating spread, Infection with signs or symptoms of systemic spread, Infection with signs of potentially fatal systemic sepsis, Immunocompromise (e.g., human immunodeficiency virus infection, chemotherapy, antiretroviral therapy, disease-modifying antirheumatic drugs), Collection of pus with surrounding granulation; painful swelling with induration and central fluctuance; possible overlying skin necrosis; signs or symptoms of infection, Cat bites become infected more often than dog or human bites (30% to 50%, up to 20%, and 10% to 50%, respectively); infection sets in 8 to 12 hours after animal bites; human bites may transmit herpes, hepatitis, or human immunodeficiency virus; may involve tendons, tendon sheaths, bone, and joints, Traumatic or spontaneous; severe pain at injury site followed by skin changes (e.g., pale, bronze, purplish red), tenderness, induration, blistering, and tissue crepitus; diaphoresis, fever, hypotension, and tachycardia, Infection or inflammation of the hair follicles; tends to occur in areas with increased sweating; associated with acne or steroid use; painful or painless pustule with underlying swelling, Genital, groin, or perineal involvement; cellulitis, and signs or symptoms of infection, Walled-off collection of pus; painful, firm swelling; systemic features of infection; carbuncles are larger, deeper, and involve skin and subcutaneous tissue over thicker skin of neck, back, and lateral thighs, and drain through multiple pores, Common in infants and children; affects skin of nose, mouth, or limbs; mild soreness, redness, vesicles, and crusting; may cause glomerulonephritis; vesicles may enlarge (bullae); may spread to lymph nodes, bone, joints, or lung, Spreading infection of subcutaneous tissue; usually affects genitalia, perineum, or lower extremities; severe, constant pain; signs or symptoms of infection. Prophylactic antibiotic use may reduce the incidence of infection in human bite wounds. At home, the following post-operative care is recommended, after Bartholin's Gland Abscess Drainage procedure: Keep the incision site clean and dry; Use warm compress to relieve incisional pain; Use cotton underwear; Avoid tight . You should also be able to answer questions about your symptoms, such as: To identify the type of infection you have, your doctor may send pus drained from the area to a lab for analysis. During this time, new skin will grow from the bottom of the abscess and from around the sides of the wound. Fournier gangrene (necrotizing fasciitis) is a surgical emergency and requires prompt hemodynamic resuscitation, broad spectrum antibiotics, and . You can pull the dirty gauze out, and gently tuck a fresh strip of ribbon gauze (use one-quarter inch width ribbon gauze for most abscesses, which you can buy at a drugstore) inside the wound. Do this once a day until packing is gone. Sometimes draining occurs on its own, but generally it must be opened with the help of a warm compress or by a doctor in a procedure called incision and drainage (I&D). x[[oF~0RaoEQqn8[mdKJR6~8FEisf\s8.l9z6_]6m:+o7w_]B*q|J Overlaying skin can become especially fragile and be easily torn away, creating a large raw spot. Ask the patient to return to clinic only as needed. Intravenous antibiotics should be continued until the clinical picture improves, the patient can tolerate oral intake, and drainage or debridement is completed. Wounds often become colonized by normal skin flora (gram-positive cocci, gram-negative bacilli, and anaerobes), but most immunocompetent patients will not develop an infection. Regardless of the . A moist wound bed stimulates epithelial cells to migrate across the wound bed and resurface the wound.8 A dry environment leads to cell desiccation and causes scab formation, which delays wound healing. If this dressing becomes soaked with drainage, it will need to be changed. The Infectious Diseases Society of America uses several clinical indicators to help stage the severity of wounds: those without purulence or inflammation are considered noninfected, and infected wounds are classified as mild, moderate, or severe based on their size and depth, surrounding cellulitis, tissue involvement, and presence of systemic or metabolic findings30,32 (Table 23033 ). Last updated on Feb 6, 2023. The standard treatment for an abscess is an abscess I&D. During this procedure, your general surgeon will numb the surface of your skin, and an incision will be made to drain pus and debris from the boil. Incisions along the radial side of the digit should be avoided to prevent painful scar with pinch maneuvers. For very large abscess cavities, you can use additional small incisions. Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. The abscess after some time will look raw and will at some point stop draining pus. Extensive description of the technique for incision and drainage is found elsewhere (see "Techniques for skin abscess drainage"). exclude or treat people differently because of race, color, national origin, age, disability, sex, Be careful not to burn yourself. If the abscess was packed (with a cotton wick), leave it in until instructed by your clinician to remove the packing or return for re-evaluation. Are there other treatments that can be used to heal skin abscesses? %PDF-1.5 Large incisions are not necessary to drain breast abscesses. Predisposing factors for SSTIs include reduced tissue vascularity and oxygenation, increased peripheral fluid stasis and risk of skin trauma, and decreased ability to combat infections. Accessibility However, there are several reasons for hospitalization or referral (Table 3).2830,36,38,39, Patients with severe wound infections may require treatment with intravenous antibiotics, with possible referral for exploration, incision, drainage, imaging, or plastic surgery.38,39, Necrotizing fasciitis is a rare but life-threatening infection that may result from traumatic or surgical wounds. All rights reserved. An abscess is sometimes called a boil. endobj Most community-acquired infections are caused by methicillin-resistant Staphylococcus aureus and beta-hemolytic streptococcus. For example, diabetes increases the risk of infection-associated complications fivefold.14 Comorbidities and mechanisms of injury can determine the bacteriology of SSTIs (Table 3).5,15 For instance, Pseudomonas aeruginosa infections are associated with intravenous drug use and hot tub use, and patients with neutropenia more often develop infections caused by gram-negative bacteria, anaerobes, and fungi. The above information is an educational aid only. Now with an ingress and an egress, you can decompress the abscess. Discover home remedies for boils, such as a warm compress, oil, and turmeric. 33O(d9r"nf8bh =-*k6M&4B 3J=yD)S'|}Zy#O 5\TCwE#!,k4Uy>vkcb/NB/] %H837 q'_/e2rM4^zU7z5V^(5*|mfR7`fz6B Read on to learn more about this procedure, the recovery time, and the likelihood of recurrence. See permissionsforcopyrightquestions and/or permission requests. Monomicrobial necrotizing fasciitis caused by streptococcal and clostridial infections is treated with penicillin G and clindamycin; S. aureus infections are treated according to susceptibilities. A doctor will numb the area around the abscess, make a small incision, and allow the pus. Nonsuperficial mild to moderate wound infections can be treated with oral antibiotics. The search included systematic reviews, meta-analyses, reviews of clinical trials and other primary sources, and evidence-based guidelines. Plain radiography, ultrasonography, computed tomography, or magnetic resonance imaging may show soft tissue edema or fascial thickening, fluid collections, or soft tissue air. & Accessibility Requirements and Patients' Bill of Rights. Continue to do this until the skin opening has closed. Patients with complicated infections, including suspected necrotizing fasciitis and gangrene, require empiric polymicrobial antibiotic coverage, inpatient treatment, and surgical consultation for. Examples of local anesthetics include lidocaine and bupivacaine. Along with the causes of dark, Split nails are often caused by an injury such as a stubbed toe or receiving a severe blow to a finger or thumb. CB2ft U xf3jpo@0DP*(Q_(^~&i}\"3R T&3vjg-==e>5yw/Ls[?Y]ounY'vj;!f8 BiO59P]R)B}7B\0Dz=vF1lhuGh]G'x(#1#aK If the infected area of your current abscess is treated thoroughly, typically theres no reason a new abscess will form there again. HHS Vulnerability Disclosure, Help Serious complications from infected animal or human bites include septic arthritis, osteomyelitis, subcutaneous abscess, tendinitis, and bacteremia.30 Common organisms in domestic animal bite wounds include Pasteurella multocida, S. aureus, Bacteroides tectum, and Fusobacterium, Capnocytophaga, and Porphyromonas species. Severe burns and wounds that cover large areas of the body or involve the face, joints, bone, tendons, or nerves should generally be referred to wound care specialists. May 7, 2013 #1 . Superficial mild infections (e.g., impetigo, mild cellulitis from abrasions or lacerations) are usually caused by staphylococci and streptococci and can be treated with topical antimicrobials, such as bacitracin, polymyxin B/bacitracin/neomycin, and mupirocin (Bactroban).31 Metronidazole gel 0.75% can be used alone or in combination with other antibiotics if anaerobes are suspected. Resources| Incision and drainage (I&D) remains the standard of care; however, significant variability exists in the treatment of abscesses after I&D. The skin is left open and the cavity heals from inside out . Percutaneous abscess drainage uses imaging guidance to place a needle or catheter through the skin into the abscess to remove or drain the infected fluid. Because wounds can quickly become infected, the most important aspect of treating a minor wound is irrigation and cleaning. Your wound does not start to heal after a few days. National Library of Medicine This usually depends on the size and severity of the abscess. 2 0 obj Before this procedure, patients might need to begin with antibiotic therapy to treat and prevent any other infections. Do this as long as you have pain in your anal area. Do not let your wound dry out. Smaller abscesses may not need to be drained to disappear. 3 0 obj An incision is made on the breast over the abscess and a sterile instrument is inserted to break open small pockets of pus. Nondiscrimination Initial antimicrobial choice is empiric, and in simple infections should cover Staphylococcus and Streptococcus species. The https:// ensures that you are connecting to the It can be caused by conditions that range from mild, Learn all about dark circles under your eyes. https://www.aafp.org/afp/2014/0815/p239.html. Continued drainage from the abscess will spoil the dressing and it is therefore necessary to change this at least on a daily basis or more frequently if the dressing becomes particularly soiled. Dog and cat bites in an immunocompromised host and those that involve the face or hand, periosteum, or joint capsule are typically treated with a beta-lactam antibiotic or beta-lactamase inhibitor (e.g., amoxicillin/clavulanate [Augmentin]).5 In patients allergic to penicillin, a combination of trimethoprim/sulfamethoxazole or a quinolone with clindamycin or metronidazole (Flagyl) can be used. In this case, youll need a ride home. Care for Your Open Wound, or Draining Abscess Careful attention will help your wound heal smoothly. Medically reviewed by Drugs.com. Care should be taken to avoid injecting anesthetic into the abscess cavity, as this will increase pressure (and thus pain for the patient) and is unlikely to successfully anesthetize. <>>> 98 0 obj <>stream You have a fever or chills. The recommended duration of antibiotic therapy for hospitalized patients is seven to 14 days. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); This field is for validation purposes and should be left unchanged. Although patients are often instructed to keep their wounds covered and dry after suture placement, sutures can get wet within the first 24 to 48 hours without increasing the risk of infection. It is the primary treatment for skin and soft tissue abscesses, with or without adjunctive antibiotic therapy. The RCTs failed to show decreases in treatment failure rates with antibiotics, but two studies demonstrated a short-term decrease in new lesion formation. They may make a small incision in your skin over the abscess, then insert a thin plastic tube called a drainage catheter into it. A small amount of bloody discharge on the dressing is normal. Tap water produces similar outcomes to sterile saline irrigation of minor wounds. Widespread fungal infection is a rare but serious complication of broad-spectrum antibiotic use in burns. Leave pressure dressing on and dry for 24 hours. 02:00. You should see a doctor if the following symptoms develop: A doctor can usually diagnose a skin abscess by examining it. Doral Urgent Care. Diwan Z, Trikha S, Etemad-Shahidi S, Virmani S, Denning C, Al-Mukhtar Y, Rennie C, Penny A, Jamali Y, Edwards Parrish NC. There is no evidence that antiseptic irrigation is superior to sterile saline or tap water. Less commonly, percutaneous abscess drainage may be used . Careers. If a gauze packing was placed inside the abscess pocket, you may be told to remove it yourself. Depending on the size of the abscess, it may also be treated with an antibiotic and 'packed' to help it heal. If it is covered in pus and blood, that is good, because it means that the abscess is draining well. However, you should check with your doctor or a nurse about home care. If you have a severe bacterial infection, you may need to be admitted to a hospital for additional treatment and observation. The doctor may have cut an opening in the abscess so that the pus can drain out. This causes an infection and inflammation along with pain and redness. (2012). Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances. Complicated infections extending into and involving the underlying deep tissues include deep abscesses, decubitus ulcers, necrotizing fasciitis, Fournier gangrene, and infections from human or animal bites7 (Figure 4). Immunocompromised patients are more prone to SSTIs and may not demonstrate classic clinical features and laboratory findings because of their attenuated inflammatory response. 18910 South Dixie Hwy., Cutler Bay 305-585-9230 Schedule an Appointment. I&D is a time-honored method of draining abscesses to relieve pain and speed healing. Leinwand M, Downing M, Slater D, Beck M, Burton K, Moyer D. J Pediatr Surg. Percutaneous abscess drainage is generally used to remove infected fluid from the body, most commonly in the abdomen and pelvis. 0 A deeper or larger abscess may require a gauze wick to be placed inside to help keep the abscess open. The Best 8 Home Remedies for Cysts: Do They Work? First, depending on the size and depth of the cyst or abscess, the physician will bandage the wound with sterile gauze or will insert a drain to allow the abscess to continue draining as it heals. Rationale: Reduces risk of spread of bacteria. 0. This activity will focus specifically on its use in the management of cutaneous abscesses. Your healthcare provider can drain a perineal abscess. Post-operative Care following a Pilonidal Abscess Incision and Drainage procedure. This content is owned by the AAFP. Unlike other infections, antibiotics alone will not usually cure an abscess. The drainage should decrease as the wound heals over time. This is most commonly caused by a bacterial infection and can occur anywhere on the body. Necrotizing Fasciitis. 1 Abscesses can form anywhere on the body. 7400 NW 104th Ave., Doral 305-585-9250 Schedule an Appointment. You may also see pus draining from the site. We avoid using tertiary references. This allows the tissue to heal properly from inside out and helps absorb pus or blood during the healing process. $U? Wound Care Bandage: Leave bandage in place for 24 hours. Curr Opin Pediatr. Regardless of supplemental post-procedural treatment, all studies demonstrate high rates of clinical cure following I&D. The woundwill take about 1 to 2 weeks to heal, depending on the size of the abscess. 2015 Jul;17(4):420-32. doi: 10.1017/cem.2014.52. 2010 Jun;22(3):273-7. doi: 10.1097/MOP.0b013e328339421b. Incision, debridement, and packing are all key components of the treatment of an intrascrotal abscess, and failure to adequately treat may lead to the need for further debridement and drainage. Three randomized control trials (RCT) and one observational study investigated wound packing versus no packing following I&D. Once the abscess has been located, the surgeon drains the pus using the needle. Your healthcare provider has drained the pus from your abscess. Do I need antibiotics after abscess drainage? The operation is performed under general anaesthesia. endobj Its administered with a needle into the skin near the roof of the abscess where your doctor will make the incision for drainage. Author disclosure: No relevant financial affiliations. 4 0 obj Abscess Incision and Drainage Procedure Hold the scalpel between the thumb and forefinger to make initial entry directly into the abscess. eCollection 2021. Once the packing is removed, you should wash the area in the shower, or clean the area as directed by your healthcare provider. Prophylactic antibiotics have little benefit in healthy patients with clean wounds. 2004 Feb;23(2):123-7. doi: 10.1097/01.inf.0000109288.06912.21. Healthy tissue will grow from the bottom and sides of the opening until it seals over. The fluid and pus are then expressed from the wound. Search dates: February 1, 2014 to September 19, 2014. The abscess drainage procedure itself is fairly simple: If it isnt possible to use local anesthetic or the drainage will be difficult, you may need to be placed under sedation, or even general anesthesia, and treated in an operating room. A skin abscess, sometimes referred to as a boil, can form just about anywhere on the body. Diabetic lower limb infections, severe hospital-acquired infections, necrotizing infections, and head and hand infections pose higher risks of mortality and functional disability.9, Patients with simple SSTIs present with erythema, warmth, edema, and pain over the affected site. Abscess incision and drainage. First, your healthcare provider will apply a local anesthetic to the area around the abscess. Treatment of necrotizing fasciitis involves early recognition and surgical debridement of necrotic tissue, combined with high-dose broad-spectrum intravenous antibiotics. These infections are contagious and can be acquired in a hospital setting or through direct contact with another person who has the infection. endstream endobj 50 0 obj <. %PDF-1.6 % Immunocompromised patients require early treatment and antimicrobial coverage for possible atypical organisms. Brody A, Gallien J, Reed B, Hennessy J, Twiner MJ, Marogil J. Copyright 2015 by the American Academy of Family Physicians. Home| Short description: Encntr for surgical aftcr fol surgery on the skin, subcu The 2023 edition of ICD-10-CM Z48.817 became effective on October 1, 2022. 7V`}QPX`CGo1,Xf&P[+_l H An infected wound will disrupt tissue granulation and delay healing. Treatment may include debridement and wound dressings that promote granulation, tissue preservation, and moisture. Practice and instruct in good handwashing and aseptic wound care.