Department: Description: Adventist Aged Care Document Name: Skin Care and Wound Management 14/04/2014 SKIN CARE & WOUND MANAGEMENT POLICY AND PROCEDURE TABLE OF CONTENTS 1.0 PURPOSE... 2 2.0 SCOPE... 2 3.0 REFERENCES... 2 4.0 DEFINITION... 2 5.0 POLICY... 2 6.0 PROCEDURE... 3 6.1 Assessment... 3 6.2 Planning... 3 6.3 Implementation... 5 6.4 Evaluation... 5 6.5 Referrals... 5 6.6 Wound Management... 6 6.7 Pressure Ulcer Formation... 8 6.8 Pressure Ulcer Prevention... 10 7.0 FORMS... Error! Bookmark not defined. 8.0 FLOW CHART... 15 APPENDIX A: Sample dressings available for use on wounds... 16 APPENDIX B: Anatomical distribution of pressure ulcers... 17 REVISED BY: ECM AUTHORISED BY: CEO APPROVED BY: CEO SECTION CHANGES IN THIS VERSION Effective Date: Signed
1.0 PURPOSE To ensure that the skin care and wound management needs of all Residents are assessed and managed effectively to enhance the quality of life for all Residents residing at Lyrebird Villages for the Aged Inc. To ensure that issues are accurately identified, documented and appropriately managed in consultation with Residents and health care team To ensure Resident preferences are recorded and incorporated into care plan development 2.0 SCOPE This applies to all Residents residing at Lyrebird Villages for the Aged Inc. 3.0 REFERENCES Standards and Guidelines for Residential Aged Care Services, 1998: 2.7; 2.8; Aged Care Act, 1997; AS/NZS 4360:1999, Risk Management; AS/NZS ISO 9001:1998 Compliance Programs; AS/NZS ISO 9001:2000 Quality Management Systems; Documentation and Accountability Manual 1999 (Dept of Health and Ageing); Information Privacy Act, 2000; Health Records Act, 2001; Privacy Act, 1988; and Privacy Amendment (Private Sector) Act, 2000. 4.0 DEFINITION Skin Assessment: Process by which the individuals skin care and wound management needs and preferences are identified, recorded and actioned. Wound: An injury, especially one in which the skin or another external surface is torn, pierced, cut, or otherwise broken. Dressing: A dressing is an adjunct used by a person for application to a wound in order to promote healing and/or prevent further harm. 5.0 POLICY The skin care and wound management needs and preferences of Residents will be assessed and managed effectively. Care needs will be evaluated and reviewed regularly and in response to Resident needs. Residents will have access to appropriate health professionals when required. Page 2 of 17
6.0 PROCEDURE 6.1 Assessment The Initial Clinical Assessment is completed within 24 hours of admission. Any identified skin care issues are documented on the Initial Clinical Assessment. Information regarding Resident care needs and preferences is collected from assessments, progress notes, GP notes, Specialist medical practitioner notes/ letter, letters from other health care providers, discharge notes/ letters or correspondence from allied and other health care providers. Skin Assessment (including the Waterlow Scale) that identifies risk category (mild, moderate, high or severe risk of developing pressure ulcers) is completed as soon as practicable on admission as and not later than within 48 hours of admission. Residents with identified skin conditions or problems are referred to the appropriate Health Professional, such as the GP, Skin Specialist, Wound Consultant, Physiotherapist, Dietician, Podiatrist etc. Resident s skin assessment is completed on admission, or in response to a change in the Resident s condition, and return from hospital for stay longer than 3 days, and at least annually. If a pressure ulcer is found on assessment an Incident Report is completed. Ensure it states where the pressure area was acquired and the wound reported to the RN this must also be documented in progress notes. Commence Wound Assessment and take a photo. Ensure pressure area is staged and this clearly documented. RN/ EN RN/ EN RN/ EN RN/ EN RN/ EN All Care Staff 6.2 Planning On admission all Residents (whether permanent or respite), have the Initial Clinical Assessment and completed within 24 hours. RN/ EN Page 3 of 17
Planning includes identifying problem(s) from comprehensive assessments, development of goals of care, interventions/strategies, evaluation and review. This process is ongoing throughout the Resident s stay in the facility. Waterlow Score (including level of risk) is documented on the Care Plan. A Care Plan with individualised interventions is developed where a deficit is identified. Strategies for the management and prevention of pressure ulcers is included on the care plan where a mild, moderate, high or severe Waterlow Score is identified. Clear description of previous health assessments (such as wound consultant, podiatrist or other health professional etc.) and dates of last assessment are included on the care plan Preferred supplier of health services is documented on the care plan (Medical Specialist, GP, Wound Consultant, Podiatrist etc.) Care plan detail specific skin care management instructions that include but not limited to: - Skin care regimes (use of barrier/ emollient creams); - Repositioning times (write actual time on charti); - Aids (including pressure reducing foam mattresses, alternating surface mattress, sheep skin products, wedges, cushions (air, gel or water), limb protectors, splints, guards and other equipment as required); - Moisture reduction (refer to Continence Management); - Relevant lifting/ transferring procedures. *Note: Where an alternating surface mattress is used, the name of the mattress and specific instructions such as pressure levels is recorded on the care plan. Supplier/ repairer details are recorded on the care plan to ensure they are accessible when required. RN/ EN RN/ EN RN RN/ EN RN/ EN RN/ EN RN Page 4 of 17
6.3 Implementation Each Resident receives care as prescribed on their individualised Care Plan. Equipment and resources required to provide care are identified and where possible (as per Specified Care and Services) provided. Staff receive education on skin care and wound management regularly and in response to identified knowledge deficits or incidents. 6.4 Evaluation Residents care plan is evaluated in response to changes in Residents condition, needs, preferences and at least 2 monthly. New or ineffectively managed problems are reassessed and where necessary Residents are referred to appropriate health professionals. Braden Score is reviewed if a Resident experiences a wound, change in mobility or continence status or if there is a change in their skin condition or general condition. All wounds are listed on the monthly Current Wound Summary List. At month s end, existing active wounds are transferred to the next month for tracking. A summary report is generated and forwarded to the ECM, by the CM no later than the 7 th day of the next month. All Care Staff RN/EN RN RN/ EN RN/ EN All Care Staff CM/ECM 6.5 Referrals Where necessary Residents are referred to appropriate health care providers to manage identified problems with skin condition and wound management (GP or Allied Health professional such as a Wound Consultant) RN/ EN Page 5 of 17
6.6 Wound Management All skin tears, bruises, burns, pressure areas or other traumatic injuries of unknown cause or as a result of an accident/ incident are recorded on an Incident Report, in the Residents progress notes and the Charge Nurse notified. Next of Kin (NOK) are also notified as per their identified wishes. The RN manages wound care and records their input on the Wound Assessment and the Residents progress notes. Each time the wound is dressed the Wound Assessment is filled out a photo is taken at initial assessment. The following information is included when a dressing is changed: - Size of wound (length and width in cms); - Condition of the wound; - Whether the wound is improving in appearance; - Pain experienced by Resident; - Exudate &/ or signs of infection; - The dressing material used; - When the dressing/ wound is to be reviewed; - When the dressing is to be replaced. - Photos to be taken regularly as wound improves or changes. RN Div-1 s, Wound Consultants or GPs are the professional that can change or update directives (type and frequency of dressing) on the Wound Management Plans. Any changes in the condition or status of a wound is reported to the RN/EN or Resident s GP. Appendix A provides an overview of dressing materials available to assist with management of wounds. Dressing Materials All dressing materials are used only on the individual Resident. If only a portion of the dressing material is required it is dated, sealed and used only for that Resident. All Care Staff RN EN/RN EN/RN RN All Care Staff RN/EN EN/RN Page 6 of 17
Staff are to adhere to infection control guidelines when providing wound care including the following: Advise Resident of need to dress wound; Clean trolley or surface to be used before commencing dressing; Attach a small rubbish bag to the side of the area (trolley or bench top); Wash hands before commencing dressing and handling dressing materials; Ensure you have all required equipment ready for use and do not have to stop during the procedure to retrieve required articles (dressing pack, dressing materials, cleaning solutions, tapes etc.); If a Resident has multiple wounds, attend to the cleanest wound first. Infected or wounds with a large amount of exudate should be attended to last; Throughout the procedure, use a hand sanitizer gel to cleanse hands after touching an unclean surface, such as Resident skin; Dispose of all used dressing materials into rubbish bag. Tie bag up and remove gloves; Dispose of rubbish in infectious waste bags, wash hands and clean down trolley/ area that has been used again; Advise Resident of the condition of the wound and the frequency the dressing is to be attended; Document all findings on the Residents Wound Management Care Plan or progress notes; Ensure CC is notified of condition of wound (report any changes). Guidelines for the management of skin tears Wash area with normal saline. If skin has not been removed, replace the skin over the graze and cover with steri strips to adhere the loose skin to the graze. Cover with a film type dressing and observe the wound daily until healed. If any sign of infection notify GP. Leave dressing intact for 7 to 10 days or remove if wound RN/EN RN/EN Page 7 of 17
appears infected Signs of a wound infection Red skin area around the wound. Heat around the wound. Green or yellow exudate. Offensive odour. Cellulitis should be marked with a black pen in order to track its progression and the date written on/ next to the marking. Oedema or swelling of limb. Painful limb. Febrile (temperature above 37.5 degrees Celsius). Feeling generally unwell. Enlarged lymph nodes. The RN is notified of any changes in the wounds condition, or when an infection or deterioration of the wound is suspected. A wound where there is a suspected infection is referred to a GP for review. This may include dressing type change, a swab of the wound and/ or commencement of antibiotics. All Care Staff Pain Management It is important to ensure the Resident receives adequate analgesia prior to performing dressings that are painful to the Resident. Any increase in pain or a decrease in sensation is reported immediately to the RN for follow up. All Care Staff 6.7 Pressure Ulcer Formation All care is taken to prevent pressure area formation. See Appendix B for sites of potential pressure area formation. All Care Staff Page 8 of 17
Residents access aids to assist with the reduction in risk and/ or management of pressure areas. This may include but not limited to: - Skin care regimes (use of barrier/ emollient creams); - Repositioning times (write actual time, not just 2/24); - Aids (including pressure reducing foam mattresses, alternating surface mattress, sheep skin products, wedges, cushions (air, gel or water), limb protectors, splints, guards and other equipment as required); - Moisture reduction (refer to Continence Management); - Relevant lifting/ transferring procedures. Pressure Ulcers are more likely to occur to the areas located over bony prominences (see Appendix B) All Care Staff Page 9 of 17
Pressure ulcer wounds are staged according to the depth/ level of damage and treated accordingly Figure 1 Staging description of wounds All Staff www.columbiasurgery.org/pat/wound/pressure.html. Accessed May, 2010 6.8 Pressure Ulcer Prevention Factors contributing to the development of pressure ulcers include the following: - Friction rubbing against the superficial skin layers; - Shear oppositional force against the skin; - Moisture. Friction Friction injuries involve the superficial skin layers. Occurs when moving a Resident across a coarse surface All Staff All Staff Page 10 of 17
Shear (might be injury from equipment think of lifting machines, wheelchairs etc.). May be as a result of rubbing or incorrect fitting clothes. High risk persons: Agitated or confused (impaired cognitive ability); Those with limb spasticity (disabled, CVA etc.); Impaired mobility; Incontinent faecal or urine or both. Prevent with heel protectors, stockings, elevation of heels, skin moisturisers. Shear diminishes blood supply to skin. Frequently caused by incorrect positioning and incorrect use of aids and equipment (see Figure 2). Use positioning, transferring & turning techniques to minimize friction/shear injury. Shear forces often occur in our deeper tissues when the surface of the skin remains attached to items (such as bed linen) while our bones, muscles and deeper tissues move in an opposite direction By keeping the knees slightly elevated and the whole position slightly reclined (more chair like), the risk of causing skin damage as a result of shearing decreases dramatically. It is preferable that the head of the bed is not raised much above 30 degrees when a Resident is resting as this will increase shear force (see Figure 3). All Staff Figure 2 Demonstration of shearing force Page 11 of 17
Figure 3 Correct positioning All Staff Moisture Moisture can come from: Incontinence (urinary or faecal); Sweating/ perspiration; Being on a mattress with a non breathable cover (such as vinyl); Saliva; Wound drainage; Nasal secretions; PEG leakage. Constant exposure to bodily fluids can cause the skin to become waterlogged and begin to breakdown (macerated). Excessively dry skin is prone to cracking and therefore skin breakdown. All Staff Page 12 of 17
Nutritional Status Residents who are malnourished and/ or emaciated often have muscle wasting and their skin tissue is more likely to experience damage. Also due to their emaciation they are more likely to have prominent bony areas which provide points for pressure areas to develop. Many Residents may also have specific nutritional deficiencies such as vitamin C, B12, D & E which can all contribute to skin healing. Mineral and other deficiencies may also be evident such as Zinc and some amino acids which are necessary for new cell growth and therefore wound healing. Poorly nourished or dehydrated individuals are also more likely to have altered blood circulation which also impacts on wound healing. Residents who are obese have increased skin folds, which are more prone to excoriation, can also be malnourished and may have altered mobility. As a result they are at risk of developing skin integrity issues. All Staff Page 13 of 17
Other factors which may affect skin Medical conditions: Diabetes decreased blood and nerve supply to the skin (particularly hands and feet which is known as peripheral neuropathy) meaning the skin is more likely to be damaged and less able to heal; Cardiovascular disease often indicating a decreased blood supply to limbs and therefore a decreased ability to heal; Poor nutrition may be due to being undernourished (cachexia very skinny and frail) or from a particular deficit such as B 12 deficiency leading to anaemia, zinc deficiency (zinc aids healing), vitamin C deficiency (vitamin C aids healing), poor protein intake (protein needed to build tissue), dehydration (can cause skin to be thin and be papery). Obesity there are less blood vessels in fat than there are in muscle. Possibly eating an unbalanced diet; Medications long term steroids (hydrocortisone or prednisolone) or anti-inflammatory medication causing skin to become tissue thin and papery, also excessive bleeding. Warfarin causes excessive bleeding and bruising; History of skin conditions such as eczema, dermatitis, dry/ excoriated skin, skin cancers etc.; Poor mobility less able to move, decreased blood supply increased risk of damage; Paraplegia/ numbness (think CVA, Parkinson s Disease ) more at risk of damage to skin due to inability to feel the damage; Incontinence whether urine or faecal, as this increased moisture and irritation to the skin causes an increased risk of damage. All Staff Page 14 of 17
7.0 FLOW CHART 1. Resident Admitted The Initial Clinical Assessment is completed on all Residents within 24 hours of admission Skin Assessment including Waterlow Scale is completed and is recorded on the Resident s care plan, including identified level of risk. Care Plan is developed within 60 days of admission and is reviewed 3 monthly All required equipment or care is clearly described on the care plan All identified care needs and interests are being appropriately managed Yes Care continues to be provided as per care plan No Resident reassessed OR referred to appropriate health professional (such as a GP or a wound consultant) for assessment and care management plan. Findings and management recorded in the progress notes and on new assessment and care plan. Subsequent care is evaluated 2 monthly, as per regular care plan reviews. Page 15 of 17
APPENDIX A: Sample Common dressings available for use on wounds Category Description Advantages Disadvantages Indications Films (Opsite, Tegaderm, others) Transparent, gaspermeable polyurethane film that mimics the function of the skin Transparent, waterproof, single dressing may remain in place 5-7 days Provide no cushioning of wound Stage I ulcers Foams (Allevyn, Lyofoam, others) Polyurethane semi permeable foam Transparent, waterproof, cushion wound surface, maintain moist wound environment, absorb excess wound exudate Cover wrap or dressing necessary Non infected stage II or III ulcers that are not completely covered by eschar Hydrocolloid s (Duoderm, Tegasorb, Comfeel, others) Self-adhesive semipermeable or occlusive dressing composed of a hydrocolloid material that interacts with wound fluid and forms a gel that sits on the wound surface Self-adhesive; create moist wound environment; promote autolysis, angiogenesis, and granulation; single dressing may remain in place 5-7 days; little nursing care required May fall off highly exudative wounds, can melt and stick to clothing or bedding Non infected stage II or III wounds with light to moderate exudate; ideal for smaller, solitary ulcers Hydrogels (Purilon gel, Intrasite gel, others) Amorphous, water- or glycerin-based gel composed of a threedimensional hydrophilic polymer Highly absorbent, transparent, conform to wound surface, can be used for stage IV ulcers Dehydrate easily, require additional cover wrap or dressing Stage II to IV ulcers with moderate drainage Alginates (Sorbsan, Mesalt, Kaltostat, others) Highly absorbent material derived from seaweed Highly absorbent, conform to wound shape Cause desiccation of the wound, require additional cover wrap or dressing do not use Kaltostat for longer than 24 hours as this dressing can leave fibers in the wound base that prevent long term healing. Stage III or IV wounds with copious drainage and to stop a bleeding wound Australian Wound Management Association Clinical Practice Guidelines For The Prediction and Prevention Of Pressure Ulcers. 2001 Page 16 of 17
APPENDIX B: Anatomical distribution of pressure ulcers Pressure Ulcer Point Prevalence Survey 2004 Department of Human Services, Victoria. Page 17 of 17