Nursing Protocol TREATMENT SKIN CARE BUNDLE. Note: The patient s MD should be notified of the presence of any skin abnormalities.

Transcription

1 Nursing Protocol TREATMENT SKIN CARE BUNDLE Page 1 of 4 Note: The patient s MD should be notified of the presence of any skin abnormalities. Skin Problem Date Time Initials Interventions Date Time Initials Incontinence Cleanse skin with soap and water or Incontinence Peri wash Skin cleanser Every 12 hours. Pat dry. Intact Skin Apply Critic Aid Clear Ointment every 4 hours and PRN (a small amount covers a large area). Cleanse incontinence off skin with incontinence wipes. d. May initiate urinary condom catheter (available for male urinary incontinence Sizes: pediatric, small, medium and large) PRN. Use skin sealant for penile skin protection. Change three times a week and PRN (example: M, W, F or T, Th, S). e. May initiate Hollister Fecal Pounch (CSR #6105) for liquid diarrhea and change every other day and PRN. Protect periwound skin with skin sealant. Apply as directed by manufacturer. f. Flexiseal fecal incontinence device is used upon a MD s ORDER ONLY for liquid diarrhe PH TSCB 0908PH PHY00229pg1

2 Incontinence Non intact (Macerated Skin) Skin Tear: d. Repeat steps b and e. f. Cleanse skin with wound cleanser (CSR # 0046) every 24 hours. Pat dry. Sprinkle affected areas with stomahesive powder (CSR #6117) then dust off excess Powder every 24 hours. Spray area with 3M Cavilon No Sting Protective Barrier Film Spray (CSR #6145) every 24 hours. Apply Critic Aid Clear Paste (small amount covers a large area) and then reapply every 4 hours and PRN. Cleanse incontinent stool off skin with incontinence wipes PRN. Change Dressing Every 7 days and PRN if loose or suspect infection: (when removing old Tegaderm, use the stretch and release method to remove it) Cleanse with normal saline Page 2 of 4 Protect periwound skin with skin sealant (Skin Prep, Shield Skin...) Reposition skin flap in place if it is present and secure it with Steri strip. d. Apply Tegaderm Blisters and/or Abrasions Change dressings every 24 hours: Cleanse with wound cleaner Cover with Xeroform gauze double folded. Secure in place with Kerlex Roll or 4 x 4 gauze Note: If tape is used to secure dressing, protect skin with skin sealant prior to tape application. PH TSCB 0908PH PHY00229pg2

3 Page 3 of 4 Skin Problem Date Time Initials Interventions Date Time Initials Mild Fungal Rash Apply Critic Aid Clear AF to area every 12 hours. Keep area clean and dry. If located under the breasts or in skin folds, apply ABD pad to absorb excess mositure. If located in scrotal area, apply a scrotal sling made from ABD pads taped end to end to each other to absorb excess moisture. Stage I Pressure Ulcer Remove source of pressure with strict pressure relief interventions. Make sure Pressure Ulcer Prevention Skin Bundle has been initiated. Protect skin with Tegaderm and/or Cavilon 3 M No String Protective Barrier Film Spray (CSR #6145). Stage II Pressure Ulcer Obtain ET consult. Remove source of pressure and make sure Pressure Ulcer Prevention Skin Bundle has been initiated. Apply protective dressing and change every other day. cleanse with wound cleanser protect periwound skin with a skin sealant (Shield Skin) may apply any one of the following dressings: Tegaderm Polymem Foam Dressing covered with Tegaderm (use if drainage is present) Extra Thin Duoderm (CSR #6012) PH TSCB 0908PH PHY00229pg3

4 Page 4 of 4 Skin Problem Date Time Initials Interventions Date Time Initials Stage III or IV Pressure Ulcer Notify MD Obtain ET consult d. Make sure Pressure Ulcer Prevention Skin Bundle has been initiated. Apply moistened normal saline fluffed gauze dressing every 8 hours. cleanse with wound cleanser protect periwound skin with skin sealant prior to dressing application. Developed: February 2006 Revised: May 2007 Revised: September 2008 PH TSCB 0908PH PHY00229pg4

5 TREATMENT SKIN CARE BUNDLE ORDERS KARDEX COPY (PLEASE CUT CORRESPONDING ORDER CARD(S) AND PLACE ON KARDEX) INCONTINENCE SKIN CARE ON INTACT SKIN Cleanse skin with soap and water or Incontinence Peri wash Skin cleanser Every 12 hours. Pat dry. Apply Critic Aid Clear Ointment every 4 hours and prn (a small amount covers a large area). Cleanse incontinence off skin with incontinence wipes. d. May initiate urinary condom catheter (available for male urinary incontinence Sizes: pediatric, small, medium and large) prn. Use skin sealant for penile skin protection. Change three times a week and prn (example: M, W, F or T, Th, S). May initiate Hollister Fecal Pouch (CSR #6105) for liquid diarrhea and change every other day and prn. Protect periwound skin with Skin sealant. Apply as directed by manufacturer. INCONTINENCE SKIN CARE ON NON INTACT SKIN Cleanse skin with wound cleanser (CSR #0046) every 24 hours. Pat dry. Sprinkle affected areas with stomahesive powder (CSR #6117) then dust off excess Powder every 24 hours. Spray area with 3M Cavilon No Sting Protective Barrier Film Spray (CSR #6145) every 24 hours. d. Repeats steps b and e. Apply Critic Aid Clear Paste (small amount covers a large area) and then reapply every 4 hours and prn. f. Cleanse incontinent stool off skin with incontinence wipes prn. Blisters/ or / Abrasions Change dressings every 24 hours: Cleanse with wound cleanser. Cover with Xeroform guaze double folded. Secure in place with Kerlex Roll or 4 x 4 gauze Note: if tape is used to secure dressing, protect skin with skin sealant prior to tape application. SKIN TEAR (S) Change Dressing Every 7 days and PRN if loose or suspect infection: (when removing old Tegaderm, use the stretch and release method to remove it) Cleanse with normal saline Protect periwound skin with skin sealant (Skin Prep, Shield Skin...) Reposition skin flap in place if it is present and secure it with Steri strip. d. Apply Tegaderm Mild Fungal Rash Apply Critic Aid Clear AF to area every 12 hours. Keep area clean and dry. If located under the breasts or In skin folds apply ABD pad to absorb excess moisture. If located in scrotal area, apply A scrotal sling made from ABD pads taped end to end to each other to absorb excess mositure. NSG00119pg2

6 Stage I Pressure Ulcer Remove source of pressure with strict pressure relief interventions. Make sure Pressure Ulcer Prevention Skin Bundle has been initiated. Protect skin with Tegaderm and/or Cavilon 3 M No Sting Protective Barrier Film Spray (CSR #6145). Obtain ET consult. Stage II Pressure Ulcer Obtain ET consult. Remove source of pressure and make sure Pressure Ulcer Prevention Skin Bundle has been initiated. Apply protective dressing and change every other day. cleanse with wound cleanser protect periwound skin with a skin sealant (Shield Skin). may apply any one of the following dressings: Tegaderm Polymem Foam Dressing covered with Tegaderm. (use if drainage is present) Extra Thin Duoderm (CSR #6012) Stage III or IV Pressure Ulcer Notify MD Obtain ET consult Make sure Pressure Ulcer Prevention Skin Bundle has been initiated. d. Apply moistened normal saline fluffed gauze dressing every 8 hours. cleanse with wound cleanser protect periwound skin with skin sealant prior to dressing Developed: February 2006 Revised: September 2008 NSG00119pg3