Skin Care Assessment Prevention and Intervention · level of Braden risk and additional risk...

Effective Date: 01/01/16 Author: Heisey, Shirley S Review History: None Owner: Oxler, Karen F Revision History: 7/30/2015 Page 1 of 23

POLICY PURPOSE

To provide an interdisciplinary, standardized approach to the assessment of skin, prevention of

breakdown, and management of wounds.

GOALS

1. Identify at risk patients and initiate early interventions for prevention of skin breakdown.

2. Protect against the adverse effects of pressure, shear, friction, and moisture.

3. Reduce the incidence of hospital-acquired pressure ulcers.

SCOPE

Any licensed or unlicensed professional that has the ability to assess and/or intervene to the patient’s

Braden risk including personnel from the following areas:

- Nursing

- Physical Therapy

- Occupational Therapy

- Nutritional Services

- Respiratory

- Non licensed staff who will care for patients and document within their scope

- All patients at Lancaster General Hospital (Duke Street, WBH)

POLICY DETAILS

Supportive Data: The skin is the largest organ of the body and therefore is easily affected by all other

organ systems. A structured approach to pressure ulcer reduction can be achieved through the use of a

risk assessment scale in combination with a comprehensive skin assessment and clinical judgment.

Lyder et al (Journal of American Geriatric Society, 2012) found that individuals who developed pressure

ulcers were more likely to die during the hospital stay, have generally longer hospital stays, and were

more likely to be readmitted than those who did not acquire pressure ulcers.

POLICY TITLE: SKIN CARE – ASSESSMENT PREVENTION AND

INTERVENTION POLICY Former Policy Title:

POLICY TITLE: SKIN CARE ASSESSMENT PREVENTION AND INTERVENTION


DEFINITION(S)

Pressure Ulcer

(PU)

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a

bony prominence, as a result of pressure, or pressure in combination with shear.

Pressure – Pressure is the force that is applied vertically or perpendicular to the

surface of the skin. Pressure compresses underlying tissue and small blood vessels

hindering blood flow and nutrient supply. Tissues become ischemic and are

damaged or die.

Shear – Shear occurs when one layer of tissue slides horizontally over another,

deforming adipose and muscle tissue, and disrupting blood flow (e.g., when the

head of the bed is raised >30 degrees). Both require pressure exerted by body

against bed/chair surface to create the tissue injury.

Other location – Pressure ulcers can develop on any skin surface subject to

excess pressure such as under oxygen tubing, drainage tubing, casts, cervical

collars or other medical devices. (NDNQI, 2013)

Community

Acquired

Pressure Ulcer

(CAPU)

Pressure ulcers that developed prior to hospital admission. The existence of the pressure

ulcer(s) was documented on the admission skin assessment or the survey was done on day

1 of the patient’s hospital stay and the pressure ulcer was already present. Pressure ulcers

that are present on admission (POA) and worsen during the patient’s length of stay are

still considered community acquired.

Must be assessed and documented within 24 hours of admission or PU is

considered Hospital Acquired per NDNQI (2013).

Hospital

Acquired

Pressure Ulcer

(HAPU)

Hospital acquired refers to new pressure ulcer(s) that developed after admission to your

facility. Also termed nosocomial or facility-acquired. The patient’s admission record

should be reviewed for the documentation of a pressure ulcer. If there is no documentation

that the pressure ulcer was present on admission, then the pressure ulcer is counted as

hospital acquired. (NDNQI)

Stage I

Intact skin with non-blanchable redness of a localized area usually over a bony

prominence. Darkly pigmented skin may not have visible blanching; its color may

differ from the surrounding area. The area may be painful, firm, soft, warmer or

cooler as compared to adjacent tissue. May be difficult to detect in individuals

with dark skin tones.

Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink

wound bed, without slough. May also present as an intact or open/ruptured serum-

filled blister.

Note: This stage should not be used to describe skin tears, tape burns,

perineal dermatitis, maceration or excoriation.

Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or

muscle are not exposed. Slough may be present but does not obscure the depth of

tissue loss. May include undermining and tunneling.

Note: The bridge of the nose, ear, occiput and malleolus do not have

(adipose) subcutaneous tissue. Thus these areas with underlying cartilage

structure rarely have pressure ulcers Staged as stage III. In contrast, areas of



significant adiposity can develop extremely deep Stage III pressure ulcers.

Bone/tendon is not visible or directly palpable.

Stage IV Full thickness tissue loss with exposed bone, cartilage, tendon or muscle. Slough

or eschar may be present on some parts of the wound bed. Often include

undermining and tunneling

Note: Stage IV pressure ulcers can extend into muscle and /or supporting

structures (e.g,. fascia, tendon or joint capsule) making osteomyelitis possible.

Exposed bone/tendon is visible or directly palpable.

It is the opinion of NPUAP that cartilage serves the same anatomical function as bone.

Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage IV

http://www.npuap.org/wp-content/uploads/2012/01/Cartilage-Position-

Statement1.pdf

Mucosal

Pressure Ulcer/

Indeterminable

Pressure ulcers found on mucous membranes with a history of a medical device in

use at the location of the ulcer.

The position of the National Pressure Ulcer Advisory Panel (NPUAP) is that

pressure ulcers on mucosal surfaces are not to be staged using the pressure ulcer

staging system. It is understood that these ulcers may indeed be due to pressure,

however anatomically analogous tissue comparisons cannot be made. Further, it is

NPUAP’s position that mucosal pressure ulcers not be classified as partial or full

thickness, because the clinical assessment of the tissue does not allow the

distinction. Therefore, the position of NPUAP is that pressure ulcers on mucous

membranes be labeled as mucosal pressure ulcers without a stage identified.

(NPUAP, 2012) http://www.npuap.org/wp-

content/uploads/2012/03/Mucosal_Pressure_Ulcer_Position_Statement_final.pdf

Suspected Deep

Tissue Injury

(sDTI)

Purple or maroon localized area of discolored intact skin or blood-filled blister due

to Damage of underlying soft tissue from pressure and/or shear. The area may be

preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as

compared to adjacent tissue.

Note: sDTI may be difficult to detect in individuals with dark skin tones, Pain

may be the only symptom Evolution may include a thin blister over a dark

wound bed. The wound may further evolve and become covered by thin eschar.

Evolution may be rapid exposing additional layers of tissue even with optimal

treatment.

Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough

(yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the

wound bed.

Eschar Black or brown necrotic devitalized tissue; tissue can be loose or firmly adherent,

hard, soft, or soggy. (WOCN, 2010)

Incontinence

Associated

Dermatitis

(IAD)

An inflammation of the skin that occurs when urine or stool comes into contact

with perineal or perigenital skin. (WOCN, 2010).

http://www.npuap.org/wp-content/uploads/2012/01/Cartilage-Position-Statement1.pdf

http://www.npuap.org/wp-content/uploads/2012/01/Cartilage-Position-Statement1.pdf

http://www.npuap.org/wp-content/uploads/2012/03/Mucosal_Pressure_Ulcer_Position_Statement_final.pdf

http://www.npuap.org/wp-content/uploads/2012/03/Mucosal_Pressure_Ulcer_Position_Statement_final.pdf



Fungal

Infection

Inflammation with satellite red or white vesicles (Bryant & Nix, 2012)

Intertrigo Mild inflammatory process that occurs on opposing skin surfaces caused by

friction and moisture such as groin or axilla (Bryant & Nix, 2012)

Definitions obtained from American Nurses Association, NDNQI Data Collection Guidelines (2013)

unless otherwise noted.

http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-

stagescategories/

ROLE(S)/REPONSIBILITIES

Direct Patient Care

Providers Responsible to visually inspect skin integrity during the provision of care and

report and document any significant findings to the RN or physician.

Registered Nurse

Complete and document Braden Risk Assessment Score and head to toe skin

assessment within 8 hours of admission, daily, and with any change in condition

or transfer of care

Activate appropriate clinical practice guidelines based on patient condition and

level of Braden risk and additional risk factors

Consult Wound Care RN if any (POA) pressure ulcer worsens or progresses to

next stage and upon assessment of any newly identified unit acquired pressure

ulcer

2 RNs to validate new or changes in pressure ulcers on the off shift and weekends

when WOCN not available

Collaborate with interdisciplinary team to address early intervention based on

Braden subscores and initiate interdisciplinary plan of care

Inpatient

Wound/Ostomy

Certified RN

Validate nurse findings for POA pressure ulcers stage III, IV, suspected DTI, and

unstageable, indeterminable

Validate nurse findings for hospital/unit acquired pressure ulcers. See when to

consult the inpatient wound/ostomy nurse appendix

Registered

Dietician Collaborate with Registered Nurse and Physician to obtain appropriate nutrition

orders for at risk patients

Provide nutrition education to at risk patients and their families

Occupational

Therapy/Physical

Therapy

Collaborate with Registered Nurse to educate patient and family on positioning

techniques in bed and in chair for at risk patients

Collaborate with Physician and Registered Nurse to determine the need for a seat

cushion

Respiratory

Therapy Assess areas of skin that are in contact with respiratory equipment during routine

treatments.

Initial Risk Assessment & Reassessment Provider Any licensed professional that has the ability to assess and intervene to the

http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/



patient’s Braden risk

Initial Braden

Risk Screen

Initial Braden risk screening will be documented within 8 hours of admission.

Braden Risk

Reassessment

Braden risk reassessment will be completed daily, with any significant change

in condition, or transition in care.

PROCEDURE:

Assessment Standards

Risk Assessment: All patients will be assessed for risk of pressure ulcers and skin breakdown

using the Braden Scale, within eight hours of admission, daily, with any significant change in

condition, or transfer of department. If the patient has a Braden Score of < 18 launch Pressure

Ulcer Risk (Using Braden Scale) (Adult)

Note: The Braden Scale for Predicting Risk is a standardized tool used for determining the level

of risk for pressure ulcers in adult patients.

15-18 = mild risk

13-14 = moderate risk

10-12 = high risk

</= 9 = very high risk

Appendix A: Braden Scale for Predicting Pressure Sore Risk

Skin Assessment: Perform head to toe assessment of skin within 8 hours of admission, daily, with any

significant change in condition. On transfer of department the assessment must be documented within 4

hours of transfer. If outside the 4 hours this would be unit acquired and document in Patient Care

Summary appropriate skin LDA in Doc Flow sheets.

Major Risk Factors for the Development of Pressure Ulcers

- General state of health (poor, debilitated, moribund, elderly)

- Chronic illness (e.g., diabetes, COPD, immunosuppression)

- Poor nutritional state

- Immobility due to diagnosis of fractured hip, fractured femur, sepsis, diabetic patient

on bed rest, restraints, etc.

- Incontinence

- Oxygenation/Circulation (peripheral vascular disease, respiratory or circulatory

impairment, smoking)

- Medications (e.g., corticosteroids, chemotherapy, anticoagulants, sedatives,

analgesics)

- Altered levels of consciousness (e.g., lethargic, comatose)

- Spasticity, contractures

- Edema

- Peripheral neuropathy

- Acute care length of stay greater than or equal to 5 days

- Infection/Fever



- Diastolic BP less than 60mm Hg

- Hemodynamic instability

Assess for other extrinsic risk factors:

- Review resolved/unresolved pressure ulcer LDA’s (Lines/Drains/Airway) for current

risk of breakdown

- Use of supportive medical devices: nasal cannulas, tubes (ie: nasogastric tubes, foley

catheters, fecal management systems, etc), glasses, hearing aids, casts, respiratory

mask, immobilizers, ace wraps

- Poor hygiene

- Undergoing surgery with long operative procedures

- Prolonged time on litters

- History of skin breakdown/pressure ulcers

- Poor dentition

- Dysphagia

See Appendix D: Device-Related Skin Protection Guide

Measuring:

What: Bruises, rashes, lesions, ulcers, wounds, reddened areas, skin tears, incision lines

How: Length (L) is 12(toward patient’s head) to 6 o’clock (toward the patient’s feet)

Width (W) is 3 to 9 o’clock

Depth (D) is straight 90 degrees down into deepest wound area. To measure the depth of

a wound, use a sterile, cotton-tipped applicator

Tunneling/Sinus tract- measure longest tract using sterile cotton-tipped applicator,

Document tract length and use a clock face to indicate direction of tunneling

Undermining – measure underlying tissue void at wound edge from ** o’clock to **

o’clock using sterile cotton-tipped applicator.

Document length and use a clock face to indicate direction of tissue void

When: On admission, Weekly (Mondays), with any significant changes i.e. debridement,

growth, and with initial Negative Pressure wound dressing changes.

Documentation for prevention and treatment Pressure Ulcers:

Assessments and interventions should be documented in EMR as follows:

Prior to initial assessment review Epic documentation under discharge tab, LDA removal for

previous documented skin LDA’s

- Re- launch active LDA’s/resolve old LDA’s after skin assessment to align with current

assessment findings.

- If no LDA exists for assessed pressure ulcer then launch a new one.

- Documentation on all rows under current LDA’s

- If Pressure Ulcer Found Launch and initiate Pressure Ulcer CPG and Pressure Risk CPG

- Utilize EMR Patient Story to communicate presence of Pressure Ulcers/Wounds on

admission, discharge and intradepartmental transfer during Hand-off report.



- As part of 24 Hour Chart Check remove any Pressure Ulcer/Wound/Incision LDA that is

no longer present on patient in current admission. This can be done by clicking on

Discharge tab LDA Removal Remove Now

Education:

- Using the teach-back method, educate patients, caregivers, and healthcare providers

involved in the continuum of care about prevention, treatment and factors contributing to

recurrence of pressure ulcers. Evaluate patient/caregiver learning as evidenced by their

ability to describe the disease process and prevention/treatment plans, correct

demonstration of care, and active participation in the treatment plan.

- Document any and all teaching re: wound/pressure ulcer under appropriate education title

automatically launched when CPG launched. Additional titles can be added individually

as is appropriate.

- Utilize Clinical reference tab in EMR to provide “Your Care Instruction” education

sheets to patients and family.

Special Populations: The modified Braden Q for Neonates will be the tool used in the NICU. The

Braden Q will be used for the risk assessment of infants and pediatric patients up to the age of 8. For

patients greater than 8 years old use the Braden Scale for Adults, understanding that in the pediatric

population, most pressure injuries are caused by medical devices that the Braden Scale cannot predict.

Prevention

Interventions for all patients -

- Ambulate patient if possible

- Make sure knee is supported when elevating lower extremities

- Do not use vigorous massage over reddened areas and bony prominences

- Limit to one incontinence pad under patient

- Cleanse skin after each incontinence episode with non-irritating soaps

Note: normal pH of skin is 4.5-5.5 (acidic), choose cleansers lower on the

alkaline side, pH balanced, and lipid-based.

- Apply clean linen and incontinence pad daily and as needed

- Offer to moisturize skin with lotion daily and as needed

- Apply skin protectant cream (barrier cream) to skin that is exposed to feces,

urine, or moisture; reapply after cleansing

- Avoid positioning patient directly on bony prominences

- Utilize pressure redistribution surfaces

- Consider use of Foam Dressing per criteria listed in Appendix G

- Encourage eating and drinking if not contraindicated by Plan of Care

- Encourage patient to reposition or assist patient if they are unable to position

self. While in bed, repositioning should occur at least every 2 hours. While in

chair, repositioning should occur every hour.

- Offloading devices for the chair and heels include:

Air filled seat cushion/ SAPS

Air filled heel protector boots and padded fabric heel protector

boots. -



- Avoid positioning directly on the trochanter when using the side-lying lateral

position

- Educate patient, family members, and caregivers on pressure ulcer prevention

strategies

Interventions based on Braden Subscores

1. Sensory Perception (Score </= 3 implement following interventions)

- Teach patient and family importance of turning and positioning

- Encourage small frequent changes in position

- Use pillows to separate bony prominences

- Elevate heels off bed by placing pillow under calf muscle

- Instruct/assist patient to change position while in chair or wheelchair

- Consider limiting time in chair to one hour or less

- Use, positioning pad or mechanical lift to lift/move patient while in bed

2. Moisture (Score </= 3 implement following interventions)

- Assess and address cause of moisture

- Evaluate type of incontinence, if any (urinary, fecal, or both) and implement

toileting schedule or bowel/bladder program when appropriate

- Contain any wound drainage using sterile gauze dressing and changing upon

moderate saturation (unless specific dressing type and frequency ordered by

physician)

- Keep skin folds dry

- Use incontinence skin barrier cream and absorbent pads as needed to protect

and maintain intact skin

- Consider fecal management system if skin breakdown is already present and

patient is incontinent of stool

- Do not use incontinence briefs unless patient is out of bed, going for a test, or

going to /participating with physical therapy

3. Activity (Score </= 3 implement following interventions)

- Encourage activity as tolerated (Walk patient 3 times/day)

- Teach patient and family importance of turning and positioning to prevent

pressure ulcers

- Elevate heels off bed by placing pillow under calf muscle

- Keep head of bed (HOB) at or below 30 degrees unless medically

contraindicated to prevent shearing

- Instruct/assist patient to change position while in chair or wheelchair

- Consider limiting time in chair to one hour or less

- Use Under pad or Turning System to lift/move patient while in bed

- Consider consult to Physical Therapy/Occupational Therapy

- If patient chair-bound consult OT for seating evaluation

- Apply Sacral Foam Dressing unless contraindicated per criteria listed in

Appendix G

4. Mobility (Score </= 3 implement following interventions)

- See Activity interventions



5. Nutrition (Score </= 3 implement following interventions)-

See Appendix C: Nutrition

- Provide tray set up and assistance when required

- Offer supplements high in protein in addition to usual diet

- Consult nutrition for Braden subscore </= 2 and total Braden score of </= 18

- Record % oral intake (doc flow sheet under Nutrition)

- Record oral fluid intake (I&O documentation)

6. Friction & Shear (Score </= 2 implement following interventions)

- Use absorbent pads if needed to mechanically lift/move patient in bed

- Keep HOB at or below 30 degrees unless medically contraindicated to prevent

shearing

- Consider use of heel/elbow protectors

- Reduce pressure created by medical devices, use of foam (See Device

Appendix)

Skin Care Orders for Nursing

**When entering a Per Protocol – Cosign required order an SBAR will be completed explaining

the need for and reasoning behind the order.

Order Order Mode Special Instructions Discontinue Use

Equipment

Specialty Beds

Low Air Low

Mattress

replacement (First

Step/ ETS )

Low Airloss Bed (

Kinair)

Bariatric Bed

Air Filled seat

cushion

Air Filled Bariatric

Nursing Referral

Nursing Referral

Nursing Referral

Nursing Referral

Per Protocol–Cosign

For use treatment of

severe moisture related

skin breakdown

Recent onset paralysis,

stage 4 on trunk, post

flap graft on trunk,

Over 500lbs, or needed

for improved bed

mobility with large

abdominal girth.

Up to 350lbs- please

send home with the

patient

Over 350lbs- please

May discontinue low airloss

replacement when moisture

related skin damage resolves.



seat cushion

Turning and

Positioning System

Seating Positioning

System

required


required


required

send home with the

patient

TAPS & SAPS Please

send with patient on

discharge

Heel Protector Boots Per Protocol–Cosign

required*

Please send heel boots

with patient on

discharge


Medications

Anti-fungal

Treatment:

Miconazole Cream

with skin

barrier (BAZA)

Miconazole Cream-

for areas that don’t

need barrier cream,

(ears, nose, scalp)

Nystatin powder –

for weeping areas

above waist line


required

For the treatment of

yeast in skin folds

Topical, BID, apply to

affected areas after

washing with soap and

water, rinsing, and

patting dry.

Discontinue 7 days after skin

looks normal.

Pressure Ulcer

Treatment:

Foam Dressing

DimethiconeCream

(Hydraguard: blue

tube)

Topical apply BID)

From Pharmacy, per

protocol co-sign

required.

Appendix G: Foam

Dressing

For intact or partial

thickness wounds

including deep tissue

injuries, Stage I and

Discontinue use when skin is

intact.



Hydrogel: NSS

(Intrasite Gel)

Topical, apply BID

to affected areas and

cover with

secondary dressing.

From Pharmacy, per

protocol, co-sign

required

Stage II Pressure

ulcers. May also be

used on arms and legs

for very dry skin.

For application on full

thickness wounds

including Stage III and

Stage IV pressure

ulcers.

Discontinue use when skin is

intact.

PMR/Diet/Nursing

PT/OT Seating

Consult


required

New stage IV Pressure

Ulcer, Quadriplegic or

Paraplegic

Nutrition Consult Nursing Referral See Appendix C:

Nutrition

Fecal Management

System


required

For frequent

incontinence of stool

creating risk of skin

breakdown

See Fecal Management

System Procedure

Strategies for Safe Patient Hand-off Across the Continuum of Care

- All surgical/invasive procedural patients are considered at risk for pressure

ulcer development and standard pressure ulcer prevention is initiated

- Upon intradepartmental transfer (i.e., ED to unit, unit to pre-procedure, pre-

procedure to post-procedure, post-procedure to unit, etc) the sending RN will

communicate to the receiving RN:

- Most recent Braden Assessment Score

- Any history of previous pressure ulcer

- Any current pressure ulcers

- Following a surgery/procedure, sending RN will also include in report to

receiving RN:

- Length of time on the table

- Patient positioning during procedure

Position Areas at risk for pressure ulcer

- Supine - Scapula, occiput, elbows, sacrum, coccyx,

heels

- Lateral - Ear, acromion process, trochanter, medial



and lateral condyles of the knee, malleolus, foot

edge on involved side

- Prone/Jackknife Nose, forehead, chest, acromion process, genitalia,

breasts, iliac crests, patella, foot edge and toes

(Bryant & Nix, 2012)

RELATED DOCUMENTS

NPUAP Quick Reference Guide for Prevention

NPUAP Quick Reference Guide for Treatment

AACN Manual

APPENDICE(S): Reference Guide


Appendix B: Skin Care Orders Chart

Appendix C: Nutrition

Appendix D: Device-Related Skin Protection Guide

Appendix E: When to Consult Inpatient Wound Care Nurse

Appendix F: Molnlycke Product Guide

Appendix G: Foam Dressing

REFERENCES

American Nurses Association (2013). NDNQI Data Collection Guidelines.

Bryant, R. & Nix, D. (2012). Acute & Chronic Wounds (4th). Current management concepts.

Clinical Practice Guideline: SKIN INTEGRITY IMPAIRMENT, RISK/ACTUAL from CPM Resource

Center, Elsevier, v-Fall 2011

Clinical Practice Guideline: PRESSURE ULCER RISK (USING BRADEN SCALE) from CPM

Resource Center, Elsevier, v-Fall 2011

Clinical Practice Guideline: PRESSURE ULCER from CPM Resource Center, Elsevier, v-Fall 2011

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2009).

Prevention and treatment of pressure ulcers: quick reference guide. Washington D.C.: National Advisory

Panel. http://www.npuap.org/wp-content/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf

Lyder, C. H., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N. R., & Hunt, D. R. (2012).

Hospital-Acquired Pressure Ulcers: Results from the National Medicare Patient Safety Monitoring

System Study. Journal Of The American Geriatrics Society, 60(9), 1603-1608.

doi:http://dx.doi.org/10.1111/j.1532- 5415.2012.04106.x

http://www.npuap.org/wp-content/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf

http://www.npuap.org/wp-content/uploads/2012/03/Final_Quick_Treatment_for_web_2010.pdf

http://starnet/Nursing/Manuals/AACN%20Procedure%20Manual%20for%20Critical%20Care/Forms/AllItems.aspx



National Pressure Ulcer Advisory Panel. Pressure Ulcers with Exposed Cartilage are Stage IV Pressure

Ulcers: An NPUAP Position Statement. 2012. Available from: http://www.npuap.org/

Parslow, N., Barton, P., Harris, C., Harrison, M., Labreche, D., MacLeod, F., et al. (2005). Risk

assessment and prevention of pressure ulcers. Registered Nurses' Association of Ontario (RNAO).

Retrieved April 10, 2013, from http://www.rnao.org/Page.asp?PageID=924&ContentID=816

Wound Ostomy and Continence Nurses Society. (2010). Guideline for prevention and management of

pressure ulcers. Mount Laurel, NJ: WOCN.




Appendix B: Skin Care Order Chart



Skin Care Orders for Nursing

**When entering a Per Protocol – Cosign required order an SBAR will be completed explaining

the need for and reasoning behind the order.


Equipment

Specialty Beds

Low Air Low Mattress

replacement (First Step/

ETS)

Low Air loss Bed ( Kinair)

Bariatric Bed

Air Filled seat cushion

Air Filled Bariatric seat

cushion

Turning and Positioning

System

Seating Positioning System

Nursing Referral

Nursing Referral

Nursing Referral

Nursing Referral


required


required


required

For use treatment of

severe moisture related

skin breakdown

Recent onset paralysis,

stage IV on anatomical

trunk, post flap graft on

anatomical trunk,

Over 500lbs, or needed for

improved bed mobility

with large abdominal

girth.

Up to 350lbs- please send

home with the patient

Over 350lbs- please send

home with the patient

TAPS & SAPS Please send

with patient on discharge

May discontinue

low air loss

replacement when

moisture related

skin damage

resolves.

Heel Protector Boots Per Protocol–Cosign

required*

Please send heel boots

with patient on discharge




Medications

Anti-fungal Treatment:

Miconazole Cream

with skin barrier

(BAZA)

Miconazole Cream- for

areas that don’t need

barrier cream, (ears, nose,

scalp)

Nystatin powder – for

weeping areas above waist

line


required

For the treatment of yeast

in skin folds

Topical, BID, apply to

affected areas after

washing with soap and

water, rinsing, and patting

dry.

Discontinue 7 days

after skin looks

normal.

Pressure Ulcer Treatment:

Foam Dressing

Dimethicone Cream

(Hydraguard: blue tube)

Topical apply BID)

Hydrogel: NSS (Intrasite

Gel)

Topical, apply BID to

affected areas and cover

with secondary dressing.

From Pharmacy, per

protocol co-sign

required.

From Pharmacy, per

protocol, co-sign

required

Appendix G: Foam

Dressing

For intact or partial

thickness wounds

including deep tissue

injuries, Stage I and Stage

II Pressure ulcers. May

also be used on arms and

legs for very dry skin.

For application on full

thickness wounds

including Stage III and

Stage IV pressure ulcers.

Discontinue use

when skin is intact.

Discontinue use

when skin is intact.

PMR/Diet/Nursing

PT/OT Seating Consult Per Protocol–Cosign

required

New stage IV Pressure

Ulcer, Quadriplegic or

Paraplegic

Nutrition Consult Nursing Referral Appendix C: Nutrition

Fecal Management System Per Protocol–Cosign

required

For frequent incontinence

of stool creating risk of

skin breakdown



See Fecal Management

System Procedure

Appendix C: Nutrition

Appendix D: Device-Related Skin Protection Guide



Type & Cause Location/ Related

Signs

& Symptoms

Interventions Appearance/ Pressure

Damage

Nasal Cannulas: any pressure area not found on admission will be a UAPU Present on admission

from oxygen use at

home, but not noted on

admission will be

UAPU

Patient pulls tubing too

tight to secure

Staff applies tubing too

tightly or does not

reassess tubing every 2

hours and reposition

tubing.

Posterior ears, upper

ears, cheeks, nasal

and septum areas

May or may not have

pain

Fungal rash on

posterior ears

contributing to skin

breakdown

Educate patient not to

tighten oxygen tubing

Gray ear cushions

If no improvement after

gray foam intervention

consult wound nurses

Convert patient to Soft

Oxygen tubing

Reddened skin: blanching

Non- blanching: stage I

Partial thickness skin

breakdown: stage II

Full thickness wound with

slough: stage III (RARE on

Cartilage Nose/ ears)

Exposed bone/cartilage :

stage IV

Unstageable : wound base

covered in slough

Suspected deep tissue

injury: purple or

ecchymosis

Eye Glasses: Present on admission

from use at home, but

not noted on admission

will be UAPU

Often caused by

sleeping with glasses

on in hospital because

may not know where

there is a safe place for

their glasses.

Bridge of nose

Top of ears

Sides of temple area

May or may not have

pain

Encourage 5 to 10

minute breaks every hour

Glasses off for 20

minutes every two hours

Glasses off when

napping or sleeping at

night

Gray ear cushions on

glass stem pieces

Foam over nose if

reddened





breakdown: stage II




Exposed bone/cartilage :

stage IV


covered in slough


Diet Type

Suggested Supplement(s)

Clear Liquid Resource Breeze

High Protein Gelatin

Full Liquid

Regular

Cardiac

Low Sodium

Ensure Plus

Health Shake* (4oz portion size, good for

fluid restriction)

Diabetic Glucerna Shake

No added Sugar Health Shake* (4oz

portion size, good for fluid restriction)

Renal Nepro

Renal Shake




Signs

& Symptoms


Damage

gray foam intervention

consult wound nurses

injury: purple or

ecchymosis color

C-Pap Masks/ Oxygen Masks, ET Tubes:

Present on admission

from use at home, but

not noted on admission

will be UAPU

Patient may be pulling

at mask to increase

friction damage

Be careful when patient

is on side that mask is

not being crushed by

bed or pillow.

Posterior ears, upper

ears, cheeks, nasal

and septum areas

May or may not have

pain

Sweating increases

risk of skin

breakdown because

of increase

maceration of skin

Foam over nose and

cheek areas

Recommend foam Trach

ties with Velcro

securement for ears with

noted injury or patient

pulling on mask

May need gray ear foam

cushions over elastic

support ties on some

types of masks


interventions consult

wound nurses




breakdown: stage II




Exposed bone: stage IV


covered in slough


injury: purple or

ecchymosis color

Indeterminable: On

mucous Membranes

Fecal Management System, catheters, condom catheters:

Skin weakened from

chronic moisture and

enzymatic content of

fecal leakage on peri-

rectal skin is more

likely to develop skin

breakdown

Fecal management

tubing should be

repositioned with each

patient repositioning in

bed or prevent patient

from laying on tube

Please also refer to the

Fecal Management Rectal

Tube CPP.

Peri-rectal skin

Posterior thighs if

patient was laying on

tubing

Patient may develop

yeast rash from

increased moisture in

area

Skin barrier buttocks

paste at each

repositioning and PRN

for leakage events

Miconazole with barrier

for yeast rash BID for

redness, no improvement

in 24 hours consult

wound nurse




breakdown: stage II


slough: stage III



covered in slough


injury: purple or

ecchymosis color

Linens and Lines:




Signs

& Symptoms


Damage

Extra linens under

patient increase warmth

of skin and risk of skin

breakdown

No bottom sheets are

needed for Low Air

loss ; negate therapy of

air flow bed.

Patient laying on

tubing: SCD tubing, IV

lines, call bells, heart

monitors, foley tubing,

NG tubing, bath

blankets, wrinkled

linens, lift pad will

create focal pressure

areas on the skin.

Anywhere under the

patient

Tubing taped too

tightly to skin

Assess carefully with

each repositioning of

patient that there are no

wrinkled, extra linens

under patient.

Assess carefully that

devices are properly

positioned.




breakdown: stage II


slough: stage III



covered in slough


injury: purple or

ecchymosis color

Casts, braces, ACE wraps, SCDs and TED stockings: When applying the cast

or brace over boney

prominences pressure

areas may develop.

Any surface that can

have pressure from

the brace, ace or cast.

May appear as red,

purple or a wound

when the device is

removed.

Unexplained pain

under the device

Patients with diabetic

neuropathy , spinal

injury or stroke may

not have any pain so

skin observation is

essential for skin

protection

If brace is secured with

Velcro assess under

brace every 4 hours and

prn with pain or swelling

TED stockings reassess

every 8 hours and prn

with pain or swelling

Reassess skin under

SCD’s with each

repositioning

Access skin every 4

hours under edges of ace

wrap and loosen ACE if

limb becomes swollen

Apply padding with

foam dressing at the time

of application to known

problem areas.




breakdown: stage II






covered in slough


injury: purple or

ecchymosis color

Indeterminable: Known

pressure ulcer unable to

assess under non-removal

brace/cast.

Nasal Gastric Tube: When placing NG tube

if able place as OG

while patient has ET

tube and secure to ET

tube

When placing on nose

please do not secure

that tube is tight to

inner nares

Reassess peri tube skin

every 2 hours and more

Inner or upper nares

where tube may be

resting

Assess for moisture in

area and patient may

need topical like

bacitracin ointment to

protect skin

Secure to ET tube when

unable with Hollister

device

Reposition NG tube

every 8 hours and PRN if

any redness

Utilize the Hollister NG

tube securement device

when able.




breakdown: stage II






covered in slough


injury: purple or




Signs

& Symptoms


Damage

frequently if any

redness or excessive

moisture

Please also refer to the GI

Tube Management CPP.

ecchymosis color

Indeterminable: On

mucous Membranes

Appendix E: When to consult the Inpatient Wound- Ostomy Nurse

(After your Nursing Wound Care Assessment and Documentation)

CONSULT INPATIENT WOUND OSTOMY NURSE

Place Consult in Epic “Wound Ostomy Inpatient Nurse Consult”

All Hospital Acquired Pressure Ulcers (ALL Pressure Ulcer with Event reports placed)

All patients with an Ostomy

All Wound V.A.C.S. or other NPWT Device

Any patients on/Ordered a Low Air Loss Bed

All Pressure Ulcers Stages III and IV, suspected Deep Tissue Injuries, Unstageable

Questionable or Advancing Pressure Ulcers

CONSULT CLINICAL NURSE EDUCATORS FOR SUPPORT

(Does not require a consult to the inpatient Wound Nurses)

Questions on Initiating Nursing Interventions from Skin Care Protocol

o Yeast

o Present on Admission / Healing Pressure Ulcers Stages I and II

Patients with wound care orders and Current Physician Management

How to apply ostomy wafer

Stand by assistance for VAC dressing changes if need support

Appendix F: Molnlycke Product Guide





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