Wound and Skin

Care Protocol

05/31/2016

Kulwinder Gill

Contents

Admission Skin Assessment Cleansing Tips for- wound, skin tear, abrasion or

ulcers. Description of various bordered foam dressings

and usage tips. Usage tips for mepilex bordered sacral dressing. Description and usage indications for medihoney

products. Skin care tips for- normal/dry skin Vs IAD, MASD

or denuded skin. IAD & MASD – Available products & indications. Male urine incontinence management tips. Female urine incontinence management tips. Do’s and Don’ts for fecal incontinence skin

management. Tips for peristomal skin care and management.

Admission Skin Assessment

• Head to Toe skin check. • Special attention to Coccyx, Sacrum, Bilateral Heels. • Must be completed and Documented within 24 hours of

admission. • If POA (present on admission) Pressure Ulcer found: 1. Take Picture (with the Pt. label on a ruler /measuring tool,

remove Pt.’s name) 2. Fill out POA Pressure ulcer form. 3. Order a Low Air Loss mattress (if on the floors) 4. Place a wound consult.( Extension # 6571) • If unable to perform skin assessment on admission– due to

noncompliance or patient refusal, please document appropriately and Reattempt if possible.

• Communicate with fellow nurses and Charge to ensure

completion of thorough skin assessment within 24 hours of patient admission.

Wound/Ulcer/Abrasion or Skin tear- Cleansing Tips

Small/ single superficial wound • Hand Hygiene • Use saline syringe • 4x4 gauze- to

remove wound debris.

• Cleanse wound base first, then the periwound.

• Remove all old secretions from wound and periwound.

• Apply Barrier wipe to the periwound

Large/ Multiple Wounds • Hand Hygiene • Use wound

cleanser bottle • 4x4 gauze-to

remove wound debris.

• Wound base first then cleanse the periwound.

• Barrier spray to the periwound.

• Use cotton tip applicator to clean deep wounds

Skin Care Tips for

Normal Skin/Pt. with Good bed mobility & Dry Flaky skin/soiled feet • Can use bath wipes for

cleaning. • Dry the extra moisture

from skin folds & between the toes.

• Can use warm water and towel/ warmed shampoo cap to clean soiled feet. Not too Hot

• Leave warm towel/shampoo cap on soiled feet for few minutes, before cleaning.

• Dry the cleansed skin and apply moisture cream – Q day.

Perineal Dermatitis, Rashes, Denudement/ Wounds in perineum Or coccyx(No dressing) • Do not use bath

wipes for cleaning denuded skin.

• Use foam cleanser with disposable wipes.

• Wipe off leftover moisture with dry disposable wipes.

• Apply thin glazed layer of barrier cream on cleansed dry skin- Q shift + PRN.

• Teach your Nursing assistance the skin regimen for affected skin areas.

Medihoney Products and Usage indications. Medihoney Gel- Use with Gauze or Plain packing. Medium to Large drainage, Full thickness & abscess wounds, Deep/undermined/tunneled wounds. Change Frequency- Based on Wound drainage or Q 2-3 days, PRN. Medihoney HCS- Place directly on wound bed. Scant to Minimal Drainage, Superficial/partial thickness wounds, Abrasions, Superficial burns. Change Frequency- 3-4 days & PRN .

Bordered Dressings Silicon- Fragile skin, Knee / elbow skin tears, PUs and Large draining wounds. 3 sizes available – 4x4(small/ very absorbent, thick padding) 5x5 (medium/less padding) 7x7( Large/ Very absorbent)

Gauze- Normal skin, Incision/Closed surgical sites on hips or abdomen. Do not use if periwound skin is fragile/ sensitive 2 sizes available- Choose based on incision length

Bordered Sacral Dressing 1. Pressure ulcers on coccyx and sacrum, back and buttocks. 2. Do not use as protection for patient’s with fragile, thin and low turgor skin / for frequently incontinent patients. 3. If used for prevention, needs to be peeled off back and reapplied (if soiled then change) , Q shift to assess for soilage or skin condition underneath the dressing.

Device related pressure ulcer prevention tools

Skin Cleansing tips prior to device placement/ during changes.

• Cleanse the skin with NS wet gauze.

• Wipe the dried skin with barrier wipes.

• Cut Mepilex Lite based on where the device will be touching the skin-

1. CPAP- Forehead & NASAL RIDGE

2. ET straps- Cheek bones

3. Trach- Ant. Neck 4. Cervical collar-

shoulder blades, ant. Chest skin.

5. Oxygen tubing- behind the ears.

Prevention product and Usage indications

Incontinence Cleansing Cloth and Barrier Cloth

wipes Incontinence cleansing cloth wipes • Perineum & incontinence

cleansing use only. • Do Not use for skin folds,

except groin folds. • Permeable to fungal powders

and can be used with other barrier creams/products.

Bath wipes • For Bed bath purposes

only. • Do Not use in perineum

skin or to clean incontinence.

• Dry the skin folds after use of bath wipes.

Incontinence and Moisture associated Dermatitis/Denudement Products & Protocol. Barrier Ointment -Glaze on cleansed dermatitic skin .(

Groin, abdominal and buttock folds)- Q shift + PRN. Interdry Fabric- Cut and place a single layer in between

the dermatitis skin folds. PRN & Q day if fabric is not soiled. Do not PUT the whole sheet in the folds

Male Urine Incontinence Management Urine incontinence Penile secretions

Meatus leakage around Foley

Cut a hole in one end of the diaper, Place it in between patient’s legs

Insert the penis through the hole and fold other end of the diaper over laying first end

Female urine incontinence Management

Vaginal secretions Urine incontinence

To contain dribble of secretions

• Foam cleanser+ disposable wipes to clean, dry the skin thoroughly.

• Barrier cream glazed on the perineum skin.

• Then place incontinence pad on Vulva to absorb dribbling, drainage or urine.

• Frequency of incontinence= checking & changing of pad.

Fecal Incontinence Associated Skin Management

Do’s CLEANSE

(Foam Cleanser) DRY

(Disposable Wipes)

BARRIER CREAM (Glazed thin layer)

PROTECT

& REPEAT

(with every Incontinence)

Don'ts • DIAPER

USAGE • BODY WIPES • TOO MUCH

BARRIER CREAM

• NOT USING BARRIER CREAM

Peri-stomal Skin Care • NS wet gauze or Foam cleanser+

disposable wipes to clean the peristomal skin.

• Barrier wipe to peristomal skin – for good seal of colostomy bag adhesive.

• Change the Colostomy bag right away if leakage noted.

• Denudement of peristomal skin- Medihoney HCS pad to be placed on open areas underneath the colostomy bag adhesive.

Inform the Wound Care Nurse.

References

• Scottsdale Wound Management Guide, 2015 edition.

• WOCN Society Wound ,Ostomy and continence Management Core Curriculum Package, 2015 First edition.

• http://www.npuap.org/resources/educatinal-and-clinical-resources.