Clinical Protocol. Page 1 of 8 – Clinical Manual/Nursing Practice Manual: John Dempsey Hospital-Department of Nursing; The University of Connecticut Health Center PROTOCOL FOR: Skin Care: Care of the Patient at Risk for or with Skin Breakdown POLICY:
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1. A consult with the clinical nurse specialist will be indicated as indicated in the decision trees.
2. A consult with a clinical dietitian will be initiated for any patient with skin breakdown or who is at high risk for skin breakdown
3. All existing dressings will be removed from patients by the admitting RN on admission so that skin condition and wounds may be fully assessed. (Exception: patients admitted from OR with dressings in place.)
DESIRED PATIENT OUTCOMES: 1. Patients will maintain optimal skin integrity. 2. Patients/significant others will be instructed regarding relevant risk factors for skin breakdown and necessary measures to minimize/prevent injury.
ASSESSMENT: 1. All patients will be assessed on admission, at least once every 48 hours, and whenever the patient’s condition changes or deteriorates, for risk of potential skin breakdown and for the presence of actual skin breakdown. The frequency of assessment is outlined in the decision trees in this protocol. Risk factors that increase the risk of developing skin breakdown include: a. Immobility b. Incontinence of urine and/or stool c. Poor nutrition (inadequate dietary intake and/or impaired nutritional status) d. Obesity or cachexia e. Altered level of consciousness f. Decreased circulation or impaired sensation g. Age > 70 years h. Previous history of skin breakdown 2. Assessment should include a total body assessment from head to toe with particular attention to bony prominences, and any body areas at increased risk secondary to pressure, friction, or moisture: a. Sacrum/coccyx b. Heels c. Trochanters d. Ischia e. Ankles f. Shoulders g. Buttocks/perineum h. Occiput i. Tips of ears j. Spine 3. Existing dressings must be removed and discarded so that complete assessment may be accomplished.
STAGING SKIN BREAKDOWN: Skin breakdown is staged to classify the degree of tissue damage observed. A wound that has eschar or necrotic tissue cannot be staged. The staging is as follows: Page 2 Clinical Protocol Page 2 of 8 Clinical Manual/Nursing Practice Manual John Dempsey Hospital-Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Skin Care: Care of the Patient at Risk for or with Skin Breakdown STAGE 1: An observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: • Skin temperature (warmth or coolness), • Tissue consistency (firm or boggy feel), and/or • Sensation (pain, itching) The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. STAGE II: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. STAGE III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. STAGE IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (for example, tendon or joint capsule). Note: Undermining and sinus tracts may also be associated with Stage IV pressure ulcers. * Stage I definition from: National Pressure Ulcer Advisory Panel (1998). http://www.npuap.org/positn4.htm * Stage II-IV definitions from: Agency for Health Care Policy and Research (1992). Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, Number 3). U.S. Department of Health and Human Services. (Publication No. 92-0047), p. 8.
GENERAL NURSING CARE: 1. Refer to decision tree and Appendix A for mattress selection. 2. Any patient in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours. Positioning devices such as pillows should be used to keep bony prominences from direct contact with one another. 3. When the side-lying position is used, avoid positioning directly on the trochanter. Page 3 Clinical Protocol Page 3 of 8 Clinical Manual/Nursing Practice Manual John Dempsey Hospital-Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Skin Care: Care of the Patient at Risk for or with Skin Breakdown 4. Maintain the head of the bed at or below a thirty (30)degree angle, or flat when not contraindicated. Shearing forces are produced when adjacent surfaces slide across one another, often times resulting in skin breakdown. 5. In order to avoid shearing and/or friction injuries, use lifting devices such as a trapeze, bed linen, or patient lift to move or reposition patients in bed who cannot assist during transfers and position change. 6. Assess patient’s heels carefully for erythema. Patients with impaired mobility or who are completely immobile are at an extremely high risk for heel breakdown. Elevate heels off mattress and support calves and ankles with a pillow or IV bag so heels “float”. 7. Skin cleansing should occur at the time of soiling and at routine intervals. The frequency of skin cleansing should be individualized based on need. Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness of the skin. Use lanolin based creams/lotions; avoid lotions with high alcohol content. Protect areas between skin folds with non-adherent dressings (e.g. Telfa). 8. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. If necessary, employ appropriate incontinence devices. Water insoluble creams (e.g. zinc oxide) can be used to provide a thick protective barrier. Avoid the use of Attends or Chux/blue pads directly against the patients’ skin. 9. Appropriately pad friction areas with sheepskin when using traction, splints, or CPM machine. 10. If skin breakdown occurs: a. Assess the pressure ulcer (s) for location, staging (I-IV as described above), size, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and epithelialization. b. Do not apply heat lamp to wound; direct heat can dehydrate the wound, delay healing, and cause further injury to the area. c. Determine the appropriate dressing: Stage I: • Follow general nursing care • Apply a hydrocolloid dressing or transparent film dressing. These dressings can be used if the wound is clean and without purulent drainage. Change the dressing every 3-4 days. Page 4 Clinical Protocol Page 4 of 8 Clinical Manual/Nursing Practice Manual John Dempsey Hospital-Department of Nursing The University of Connecticut Health Center
PROTOCOL FOR: Skin Care: Care of the Patient at Risk for or with Skin Breakdown Stage II: • Follow general nursing care • Place patient on an appropriate pressure reduction surface (Appendix A) • Cleanse wound with normal saline solution • Apply a hydrocolloid dressing to wound base, making sure that the dressing adheres to at least one (1) inch of healthy, intact skin. Change the dressing every 3-4 days, OR • Apply a transparent dressing to a wound with a dry wound bed in order to maintain a moist wound environment. Transparent dressings should be used to cover a skin tear but should not be changed on a daily basis. A collection of drainage beneath the dressing is normal. Hydrogel ointment used to maintain a moist wound environment requires an order from a LIP. OR • Apply Aquacel (pad or ribbon dressing) on moderately to heavily exuding wounds (i.e. venous stasis ulcers, pressure ulcers, diabetic ulcers, post-op wounds, superficial lacerations). This requires LIP order. Aquacel should be applied directly to the wound bed and covered with a secondary dressing. This product can stay on for up to 7 days, or until drainage saturates the secondary dressing. OR • Consult with Clinical Nurse Specialist/House Officer regarding appropriate dressing technique. Stage III-IV: • Follow general nursing care • Place patient on a pressure reduction or pressure relief surface (Appendix A) • Consult with Clinical Nurse Specialist to identify appropriate wound care management • Consult with LIP for wound assessment and related wound specialty/dressing orders d. Consult with Clinical Nurse Specialist or House Officer if: • Lesion increases in size or depth • Purulent or increased drainage develops • Eschar or necrotic tissue are present • Increased bleeding occurs • Current regimen of care is not effective and a new plan of care needs to be developed e. Refer to Decision Trees. Page 5 Clinical Protocol Page 5 of 8 Clinical Manual/Nursing Practice Manual John Dempsey Hospital-Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Skin Care: Care of the Patient at Risk for or with Skin Breakdown
NURSING INTERVENTION: Decision Trees: The following decision trees should be utilized to guide nursing management: Patient At Risk for Skin Breakdown • Ambulatory/fully mobile • Continent • Good nutrition • Post-op/Post –procedure with < 24 hours bedrest Patient with any of the following: • Incontinence • Poor nutrition • Altered level of consciousness • Limited mobility secondary to: o Prolonged sedation o Paralysis o Traction o Bedrest > 24 hours • Limited or decreased sensation • Redness over a bony prominence that lasts > 30 • Previous history of skin breakdown Low Risk for Skin Breakdown • General nursing care as outlined in protocol • Standard mattress • Skin assessment at least every shift High Risk for Skin Breakdown • General nursing care as outlined in protocol • Pressure reduction mattress • Skin assessment at least every shift • Consultation with Clinical Dietician for nutritional support • If there is persistent erythema and/or a progressive risk for skin breakdown secondary to incontinence or increased immobility, consult with CNS or House Officer regarding: o Low air loss bed o Incontinence management Page 6 Clinical Protocol Page 6 of 8 Clinical Manual/Nursing Practice Manual John Dempsey Hospital-Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Skin Care: Care of the Patient at Risk for or with Skin Breakdown Patient with Skin Breakdown • Turns independently or with minimal assistance • Continent • Adequate caloric intake • Has one or more superficial Stage II ulcerations and can be adequately positioned off areas Patient with any of the following: • Incontinence • Inadequate caloric intake • Limited mobility secondary to pain or inability to comply or cooperate with independent turning • Contractions • Restricted position • Has one or more Stage II-IV ulcerations, and cannot be adequately positioned off the affected area (s). Low Risk for Further Skin Breakdown High Risk for Further Skin Breakdown • General nursing care as outlined in protocol • Pressure reduction mattress • Skin assessment on admission and at least every 48 hours • Turn and reposition every 2 hours • Consultation with Clinical Dietician • Wound management appropriate for stage of the wound • May consult with Clinical Nurse Specialist to help identify appropriate wound Patient requires: • HOB > 30 degrees for extended periods of time • Frequent transfers • Progressive ambulation Patient requires and/or has: • Strict bedrest • Skin graft/flap protection • Terminal diagnosis • Burns • Limited transfers Low air loss Versacare Fluidized gel overlay (RIC) • General nursing care as outlined in protocol • Skin assessment at least every shift • Turn and reposition every 2 hours • Consultation with Clinical Dietician • Wound management appropriate for stage of the wound • Consultation with Clinical Nurse Specialist/HO to help identify appropriate wound treatment
Page 7 Clinical Protocol Page 7 of 8 Clinical Manual/Nursing Practice Manual John Dempsey Hospital-Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Skin Care: Care of the Patient at Risk for or with Skin Breakdown DOCUMENTATION: 1. Document risk factors for skin breakdown on admission on the Nursing Data Base. If skin breakdown is present, document the location, size (length x width x depth), stage of the area, presence of exudates or drainage, tunneling, necrotic tissue, etc. 2. Identify “Skin Integrity, Impaired” or “Potential for Impaired Skin Integrity” as a patient care problem on the nursing care plan. 3. A daily progress note is required for patients with skin breakdown to include the assessment and wound management, type of specialty bed in use, use of other equipment or devices (e.g. multi-podis boots). 4. Wounds require documentation of measurements at least Weekly. APPROVAL: Nursing Standards Committee EFFECTIVE DATE: 3/88 REVISION DATES: 12/90, 1/95, 8/96, 12/96, 3/97, 12/97, 12/02, 5/03, 10/05
Page 8 Clinical Protocol Page 8 of 8 Clinical Manual/Nursing Practice Manual John Dempsey Hospital-Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Skin Care: Care of the Patient at Risk for or with Skin Breakdown Appendix A Bed Types, Indications/Functions and Weight Capacity BED TYPE Indications/Functions Weight Capacity VersaCare by Hill Rom- JDH owned Hospital owned bed with blue mattress, bed alarm, turn assist, bed scale (see user manual on unit for full description of features) Pressure relief surface good for up to a stage III. 440 lbs First Step Select- KCI rental Air mattress overlay- appropriate for stage I-II’s when a VersaCare is not available 250 lbs KinAir- KCI rental Low air loss bed- appropriate up to a stage III or IV with frequent ambulation 300 lbs Total Care Sport (generally ICU patients, Hill Rom hospital owned) 2 layered cushioned therapeutic surface with zoned pressure relief with percussion and rotation features Pressure reduction to 350 lbs, weight capacity to 500 lbs FluidAir-KCI rental Sand/bead bed- for complicated stage III and stage IV ulcers. 250 lbs RotoProne (ICU- KCI rental) For critical care patients that meet the criteria for prone positioning. Low-air loss bed. 350 lbs BARIATIRIC CONTINUM OF CARE BariMaxx- KCI rental Basic hospital level bed 1,000 lbs BariKare-KCI rental Air surface, cardiac chair function, front exit, scale. Recommended for high risk of break down, stage I and II ulcers 850 lbs BariAir- KCI rental Low Air loss surface, front exit, percussion and pulsation, turn assist, scale. For Stage III and IV ulcers 850 lbs Bariatric Accessories- KCI rental Wheel chair Walker Commode/Shower Chair EZ lift 700 lbs 850 lbs 1,000 lbs 1,000 lbs