skin champion education robert j. dole vamc skin/wound care education
TRANSCRIPT
Skin Champion Education
Robert J. Dole VAMC
SKIN/Wound care education
Objectives• Describe the pathophysiology of wound healing• Explain the difference between acute and chronic wounds• Identify factors that impair wound healing • Describe the benefits of moist wound healing• State the principles of wound management• Explain pressure ulcer risk, skin, and wound assessment
documentation requirements.• Discuss the importance of pressure ulcer prevention• Describe how a pressure ulcer develops• Describe the key elements in pressure ulcer assessment
and staging
Anatomy of the Skin
Epidermis
• Outermost layer (epi- means upon)• Thickness from 0.1mm to 1.0mm• Slightly acidic – avg. pH 5.5• “ACID MEMBRANE”• Contains melanocytes – pigment• Made up of 4 to 5 layers depending on
location
Layers of the epidermis• Stratum corneum - horny layer - dead skin
cells (keratinized epithelium) -environment• Acid mantle protects from some fungi and
bacteria• Shed and replaced every 4 to 6 weeks
• Stratum lucidum - clear layer – single cell layer found where thickest – soles of feet• Intense enzyme activity prepares cells for
stratum corneum even though lacks nuclei
• Stratum granulosum - granular layer – 1 to 5 cells – flat cells with nuclei – aids keratin formation -
Layers of the epidermis• Stratum spinosum – cells begin to flatten
as they migrate – protein precursor of keratinized skin cells synthesized
• Stratum basale / stratum germinativum• One cell thick• Only layer that undergoes mitosis• Forms dermoepidermal junction – protrusions
known as rete ridges or epidermal ridges extend into dermis and are surrounded by vascularized dermal papillae• Support and exchange of fluid and cells
Dermis - deeper layer of skin• Collagen (strength) and elastin (elasticity)
fibers produced by fibroblasts• Extracellular matrix – gives skin its
physical characteristics• Blood and lymphatic vessels – transport O2,
nutrients and remove wastes• Nerve fibers, hair follicles, sweat glands –
contribute to sensation, temperature regulation, excretion and absorption
• Sebaceous glands – sebum lubricates and softens the skin
DermisTwo layers of connective tissue
• Papillary dermis - outermost layer• Composed of collagen and reticular fibers
important in wound healing• Capillaries transport nourishment
• Reticular dermis – innermost• Thick network of collagen bundles anchor it to
subcutaneous tissue, fasciae, muscle and bone
Subcutaneous tissue(Hypodermis)
• Layer of loose connective tissue that contains major blood and lymph vessels and nerves
• High proportion of fat cells• Fewer small blood vessels than dermis• Provides insulation, absorbs shocks to the
skeletal system
Effects of Aging• 50% reduction in cell turnover rate of stratum corneum• 20% reduction in dermal thickness• Reduction in vascularization and blood flow to the skin• Redistribution of subcutaneous tissues to stomach and
thighs• Reduced adhesion between layers• Reduced number of Langerhan’s cells – macrophages that
attack invading bacteria• 50% decrease in fibroblasts and mast cells involved in
inflammatory process• Decrease number of sweat glands• Decreased absorption• Reduced ability to sense pressure, heat and cold
Phases of Wound Healing
• Hemostasis - vasoconstriction and coagulation • collagen fibers in the damaged vessels wall
activate platelets
• Inflammation – defense and healing• Neutrophils engulf debris and bacteria• Monocytes converted to macrophages• Macrophages produce growth factors that
attract cells needed for new vessel growth, collagen for granulation and epithelialization
Phases of Wound Healing
• Proliferation • granulation tissue (connective tissue) fills the
wound• Wound edges retract/contract• Epithelium migrates across the wound
• Maturation• Shrinking and strengthening of the scar• Continues for months and even years – 80%
Hemostasis phase
Inflammatory phase
Proliferation phase
Maturation phase
Non-healing wound
Acute wounds
• Occur by intension or trauma• Begins with a sudden, single insult• Proceeds to heal in an orderly manner
• Surgical wounds• Traumatic wounds: unplanned injury to the
skin• Burns• Skin grafting
Acute wound
Chronic wounds
• Caused by underlying pathology that produces repeated and prolonged insults to the tissues
• Frequently complicated by ischemia, necrotic tissue and heavy bacterial loads
• High levels of inflammatory proteases and low levels of growth factors
Chronic wound
Factors that affect healing
• Nutrition• Oxygenation• Infection• Age• Chronic health conditions• Medications• Smoking
Nutrition• Malnutrition increases the risk of developing
pressure ulcers and delays healing• Protein is crucial for proper healing (0.8 to
1.6g/kg/day)• Collagen formation is reduced or delayed without
adequate protein• Fatty acids (lipids) used in cell structures and
inflammatory processes• Vitamins C, B-complex, A, and E and minerals iron,
copper, zinc, and calcium are important• Zinc deficiency slows epithelialization and decreases
tensile strength
Oxygenation• Wound healing depends on a regular supply of oxygen
• Critical for leukocytes to destroy bacteria and fibroblasts for collagen synthesis
• Impaired blood flow to the wound or the patients inability to take in adequate O2
• Causes of inadequate blood flow to the wound• Pressure, arterial occlusion, prolonged
vasoconstriction, PVD and atherosclerosis• Compromised perfusion more likely to impair healing
• Causes of inadequate systemic blood oxygenation• Acute and chronic conditions such as COPD,
hypothermia hypotension, hypovolemia, cardiac insufficiency
Infection
• Systemic infections (pneumonia, TB) increase metabolism and depletes the fluids, nutrients and O2 the body needs for healing
• Localized from the injury or develops secondary• Inflammatory phase lingers delaying wound healing• Metabolic by-products of bacterial ingestion
accumulate in the wound and interferes with formation of new blood vessels and collagen synthesis
• Signs: new or increased pain, exudate, redness, heat, induration, edema, malodor
Aging• Slower turnover rate in epidermal cells• Decreased O2 at the wound – increasingly fragile
capillaries and reduction in skin vascularization• Altered nutrition and hydration• Impaired function of immune or respiratory
systems• Reduced dermal and subcutaneous mass• Healed wounds lack tensile strength and are
subject to reinjury• Chronic health conditions
Chronic health conditions• Pulmonary disease, atherosclerosis, diabetes and
malignancies increase risk and interfere with wound healing
• Impaired circulation common in diabetes and conditions that cause hypoxia
• Neuropathy associated with diabetes increases risk and can impair leukocyte function
• Dehydration, ESKD, thyroid disease, heart failure, PVD, vasculitis, and other collagen vascular disorders can delay healing
Medications
• Any medication that reduces movement, circulation, or metabolic function• Sedatives • tranquilizers
• Medications that reduce the body’s ability to mount an appropriate inflammatory response• Steroids• Chemotherapeutic agents
Smoking
• Carbon dioxide binds to the hemoglobin in blood in place of oxygen
• Reduces the amount of circulating oxygen• Occurs with exposure to second hand
smoke as well• Nicotine causes vasoconstriction and
increased coagulability
Wounds/Ulcers
Principles of Wound Healing
Prevention
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PUPPI on PatrolThe Pressure Ulcer Prevention Performance Improvement (PUPPI)
team is launching a“War on Wounds!”
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PUPPI on PatrolThe Pressure Ulcer Prevention Performance Improvement (PUPPI)
team is launching a“War on Wounds!”
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PUPPI on PatrolThe Pressure Ulcer Prevention Performance Improvement (PUPPI)
team is launching a“War on Wounds!”
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PUPPI on PatrolThe Pressure Ulcer Prevention Performance Improvement (PUPPI)
team is launching a“War on Wounds!”
BRADEN INTERVENTIONS
Sensory Perception Able to respond meaningfully to pressure-related discomfort.
4. No Impairment (Provide routine skin care). 3. Slightly limited a. Encourage turning and reposition q 2 hours when in bed. Utilize pillows to separate pressure areas. When in W/C assist with position changes to alter pressure points at least every hour. Instruct and encourage active patient/family participation as able.b. Consider elevation of heels off of the bed surface with longitudinal pillows. c. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).d. When elevating HOB, gatch the knee area (elevate 10-20 degrees)e. Consider wheelchair cushion (esp. if existing skin breakdown) 2. Very limiteda. Provide above.b. Limit W/C to 1-2 hour intervals.c. Instruct to shift weight in W/C q 15 minutes.d. Use a turn sheet to lift up in bed or turn. 1. Completely limiteda. Provide all of above as needed.
Moisture
Degree to which skin is exposed to moisture.
4. Rarely moista. Instruct resident to request care as neededb. Assess and provide routine skin care as needed to keep skin clean and dry. 3. Occasionally moista. Provide above with use of incontinent care products as needed (No Rinse pH balanced cleanser, protective ointment, absorbent briefs with protective liner to prevent trapping of moisture against skin.)b. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).c. When elevating HOB, gatch the knee area (elevate 10-20 degrees) 2. Very moist.a. Provide all of above as needed.b. Assess and address cause for fecal/urinary incontinencec. Consider fecal/urinary incontinence containment device (esp. if existing skin breakdown) 1. Constantly moista. Provide all of aboveb. Apply fecal/urinary incontinence device, as able.
Activity Degree of physical activity.
4. Walks frequentlya. Encourage activity as tolerated 3. Walks occasionallya. Provide above.b. Teach patient/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes.c. Consider wheelchair cushion (esp. if existing skin breakdown) 2. Chair fasta. Provide all of aboveb. Obtain wheelchair cushion.c. Limit W/C to 1-2 hour intervals. Instruct to shift weight in W/C q 15 minutes.d. Assist as needed with turning and reposition q 2 hours when in bed. Utilize pillows to separate pressure areas.e. Consider elevation of heels off of the bed surface with longitudinal pillows. 1. Bedfasta. Provide all above, as needed.b. Consider WOCN consult for higher level support surface (esp. if existing skin breakdown)
Mobility
Ability to change and control body position.
4. No Limitation(Provide routine skin care). 3. Slightly limiteda. Assist as needed with turning and reposition q 2 hours when in bed. Utilize pillows to separate pressure areas.b. Instruct to shift weight in W/C q 15 minutes. Consider W/C cushion (esp. if existing skin breakdown).c. Consider elevation of heels off of the bed surface with longitudinal pillows. d. Consider use of foam wedges to help maintain positioning.e. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).f. When elevating HOB, gatch the knee area (elevate 10-20 degrees) 2. Very Limiteda. Provide aboveb. Limit W/C to 1-2 hour intervals 1. Completely immobilea. Provide above.b. Consider Wound Care Nurse consult for higher level support surface (esp. if there is existing skin breakdown).
Nutrition Usual food intake pattern.
4. Excellent(Provide tray set up and other routine assistance as needed). 3. Adequatea. Encourage meals and assist with meals as needed.b. Offer ordered supplements.c. Assess needs for oral care, assist PRN 2. Probably inadequatea. Provide aboveb. Consult dietician 1. Very poora. Provide aboveb. Consider WOCN consult for higher level support surface (esp. if existing skin breakdown)
Friction & Shear
3. No apparent problem (Provide routine skin care) 2. Potential problema. Use a turn sheet to lift up in bed or turn.b. When elevating HOB, gatch the knee area (elevate 10-20 degrees)c. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).d. Consider heel/elbow pads or socks. 1. Problema. Provide aboveb. Consider use of assisting devices (i.e. trapeze)
Types of Wounds
• Treat Based on Drainage• Pressure Ulcers• Diabetic Ulcers• Venous Insufficiency Ulcers• Arterial Ulcers
• Specific Treatments• Incontinence Dermatitis• Perineal Candidiasis• Skin Tears
Types of Wounds
• Found in diabetic patients with peripheral neuropathy; usually on the ball of the foot or tops of toes; prone to infection
• Approximately 15% of patients with diabetes develop foot ulcers.
• 23% of this group develop osteomyelitis
• Incidence of vascular disease is at least four times higher in patients with diabetes and increases with age and disease duration
Diabetic/Neuropathic Ulcers
Diabetic/Neuropathic Ulcers-Causes
• Pressure, secondary to peripheral neuropathy and/or arterial insufficiency• Plantar aspect of foot• Over metatarsal heads• Under heel
• Poor microvascular circulation
• Poor blood sugar control• Lack of sensation
Diabetic/NeuropathicUlcer Characteristics
• Below the ankle• Poor circulation• Neuropathy• Sites of pressure,
friction, shear• Sites of trauma
• Even wound margins
• Peri-wound callous• Round• Hemorrhagic
callous• Increased potential
for infection
Types of Wounds
Usually due to minor trauma; pretibial area of shin or above the medial ankle; superficial but difficult to heal
Venous Insufficiency Ulcers
Venous Ulcers - Causes
• Problems with venous blood return to heart
• Non-functioning or inadequate calf muscle pump
• Incompetent perforator valve
• Incompetent valves in the vein
• All lead to venous hypertension
• Venous blood pools in lower extremity and foot
Characteristics of Venous Insufficiency Ulcers
• Edema• Hyperpigmentation • Gaiter distribution• Ankle flare• Atrophy of skin• Eczema • Lipodermatosclerosis• Palpable pulses
• Irregular borders• Usually shallow• Weepy • Located on medial lower
leg and malleolus• can be circumferential
• Pain relieved by elevation• Heavily contaminated
Types of WoundsArterial Ulcers
Due to arterial occlusive disease which results in tissue necrosis; usually occur on the ankle or bony areas of the foot; painful, dry, and pale; pedal pulses diminished or absent
Characteristics of Arterial Ulcers
• Absence of hair• Atrophy below level
of occlusion• Pain upon elevation• Absence of palpable
pulse• Sites of trauma• Often bright red
granulation tissue
• Well defined borders/punched out appearance
• Minimal drainage• Usually full thickness• Usually lateral foot, can
be anywhere• Dependent rubor• Tendon exposure
Types of Wounds
Incontinence Dermatitis
Injury to the skin caused by exposure to excessive moisture, urine, and/or stool
Characterized by inflammation, rash, and possibly denuded skin
Anywhere in the sacral/coccyx, buttock, or perineal area
Types of Wounds
• Fungal/Candida infection characterized by erythematous papules and satellite lesions, and/or scaly borders
Perineal Candidiasis
Types of Wounds
Traumatic wound occurring principally
on the extremities of older adults as a result of friction and/or shearing forces which separate the epidermis from the dermis, or separate both the epidermis and the dermis from underlying structures
Incision-like skin lesion Classified based on the presence and amount of the skin flap
Skin Tears
Stage I Pressure Ulcers
• 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.
Stage I Pressure UlcersThe area may be painful,
firm, soft, warmer, or cooler as compared to adjacent tissue
Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk persons” (a heralding sign of risk).
Stage II Pressure Ulcer Partial thickness loss
of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
May present as an intact or open/ruptured serum filled blister or a shiny or dry shallow ulcer without slough or bruising
Stage II Pressure Ulcer Presents as a shiny or
dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury
Stage III Pressure Ulcer
• 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.
Stage III Pressure Ulcer
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers.
Stage IV Pressure Ulcer
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Stage IV Pressure UlcerThe depth of a stage IV
pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV 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.
Unstageable Pressure Ulcer
Full thickness 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.
Unstageable Pressure Ulcer
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on heels serves as “the body’s natural (biological) cover” and should not be removed.
Suspected Deep Tissue Injury
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.
Suspected Deep Tissue Injury
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by a thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
Definitions• Eschar: wound is covered with
thick, dry, black necrotic tissue. Eschar may be allowed to slough off naturally, or it may require surgical removal (debridement)
• Slough: a mass or layer of dead tissue separated from the surrounding or underlying tissue, usually cream or yellow in color
• Granulation Tissue: new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process
Definitions• Undermining: The wound
extends under the visible opening; a hollow between the skin surface and the wound bed that occurs when necrosis destroys the underlying tissue
• Tunneling: A narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation
• Maceration: The softening and eventual breakdown of tissue due to excess moisture, making the wound prone to infection
Pressure Ulcers—Understanding and Staging Pressure Ulcers
Treatment Goals:
MOIST wound healing Protect from trauma Moisture balance
Dressings serve to protect the wound from trauma and contamination, and facilitate healing by absorption of exudate and protection of healing surfaces
Select dressings based on wound drainage:• Dry wound (Dessicated): Wet it• Moist wound: Maintain it, prevent maceration• Mod-High draining wound (Heavy Exudate): contain
Use skin prep to protect skin from skin tears.
Cleanse ALL wounds with NS or Wound Cleanser
Date all dressings
Treatment
• Heavy Exudate• An absorptive dressing should be employed to avoid
build up of chronic wound fluid that can lead to wound maceration and inhibition of cell proliferation and healing.
• An appropriate wound dressing can remove excess wound exudate while maintaining a moist environment to accelerate wound healing
• Dressings with absorptive qualities include alginates, foams, and hydrofibers
Treatment
• Dessicated • Dessicated ulcers lack wound fluids, which provide
tissue growth factors to facilitate re-epithelialization. • Pressure ulcer healing is promoted by dressings that
maintain a moist wound environment while keeping the surrounding intact skin dry.
• Choices for a dry wound include saline moistened gauze, transparent films, hydrocolloids, hydrogels, and Tenderwet
Incontinence Dermatitis
• Moisturizing• Water-repellent protective
barrier• Apply BID, PRN
• Use: Incontinence and Radiation Dermatitis; Superficial skin breakdown causing pain
• Creates moist wound environment by stimulating capillary bed, promotes epithelium, assists in pain control.
• Does not require secondary dressing
• Apply BID & PRN
Aloe Vesta Barrier Cream
Carrington moisture barrier
Butt paste
Xenaderm Ointment (Castor Oil/Balsam Peru/Trypsin)
Wound Dressings• Wound Gel
• Hydrogel (Carrington/Carasyn)• Santyl Collagenase
• Foam• Mepitel and Lyofoam
• Non-adherent Dressing• Petrolatum Gauze• Oil/Emulsion Dressing (Adaptic)
Wound Gel
• Adds moisture• Autolytic debridement• Softens eschar
Wound-specific
Foam Dressing
Uses: dry, moist, minimal-mod drainage
Stage II, Shallow III, skin tears, abrasions, venous stasis ulcers,
Change qd, PRN
Mepilex Border
Lyofoam(special rx)
Non-adherent Dressing
Uses: Prevent adherence of dressing to wound bed; Keeps wounds/meds moist; Maintains placement of skin grafts; Decreases pain
May be used in conjunction with wound vac to prevent adherence of foam to wound
Oil based products can cause too much moisture creating macerated tissue over rims
Requires secondary dressing Usually change Daily Others: Telfa – lifts no/minimal
debris from wound base
Petrolatum Gauze
Oil/Emulsion (Adaptic)
Enzymatic Debridement
• Uses: Stage III-IV Pressure Ulcers
• Debrides mixed viable tissue
• Must be kept moist • Change daily
Collagenase ointment
Moist to Low Draining Wounds• Wound Gel
• Hydrogel (Carrasyn) • Foam• Mepilex Border
• Hydrocolloid• Restore Hydrocolloid 4x4• Restore Extra Thin 4x4 (caution!)
• Antimicrobial Gel/Ointment• Bacitracin/Bactroban
• Iodosorb Gel• Silvadene Cream
Hydrocolloid Dressings
Uses: dry, moist, minimal drainage
Stage I & II, shallow III Primary/secondary
dressing Change q 3-7 days and
PRN soiled/loose May be cut to fit Do not use on infected
wounds; caution w/diabetic wounds
Restore Hydrocolloid 4x4
Restore Extra Thin 4x4
Antimicrobial Gels/Ointments
Uses: Diabetic Foot ulcers, infected wounds-high drainage
Cadexamer Iodide based gel, provides sustained antimicrobial coverage to wounds without causing toxicity, absorbs drainage but does not allow wound to dry out
Requires secondary dressing
Change daily; potent to 72hours
Iodosorb Gel
Antimicrobial Gels/Ointments
Provides silver with significant antimicrobial properties
Can not be used on patients allergic to sulfa drugs
Requires secondary dressing
Change daily
Silvadene Cream – antibiotic gel
Antimicrobial Gels/Ointments
For wounds with dry to moderate exudate.
Use SilvaSorb Gel for a three-day (72hr) antimicrobial barrier, plus the moisture donating benefits of hydrogel.
• (we do not have this at RJD, at this time.)
Silvasorb gel
Moderate to Heavy Draining Wounds
• Calcium Alginate (heavy drainage)• Calcium Alginate – silver/AG ca+ alginate
• 7 day potency products
• Antimicrobial Gel/Ointments (moderate drainage)• Iodosorb Gel – 72hr potency• Silvadene Cream – 24hr potency
Calcium Alginate/Hydrofibers
Use: mod-large drainage Stage II, III, IV, skin tears,
venous stasis ulcers, surgical wounds, Dehisced wounds
Change daily , QOD, or PRN strikethrough drainage
May be cut to fit Needs secondary dressing Contraindicated for dry
wounds and third degree burns - adheres easily
Calcium Alginate (Restore)
Others: Aquacel Ag
Tape
• 1 or 2 inch Paper Tape• General purpose• Hypoallergenic and
latex-free • Preferred choice for
wound care to prevent skin stripping
• Vital use skin prep to protect skin pre-tape
Wound Cleanser
Cara KlenzGentleNo rinse
Normal Saline SyringeUsed to irrigate the
woundNon-antibacterial
soap
Skin Cleansing
• No-rinse, gentle cleanser
• Moisturizes and conditions skin
Aloe vesta foam cleanser
Skin Prep
Hollister prep wipes
• Protects Skin from additional breakdown from tape or moisture with plastic, copolymer layer on skin
• This layer lifted off with tape removal, not repeat lift-off top skin layer.
Moisturizers• Aloe Vesta Protective
Ointment• Provides an effective
barrier that seals out moisture, contains emollients to moisturize and is non-sensitizing and fragrance free
• A&D Ointment• Helps heal, protects,
smoothes/soothes
• Carmol Urea 20%• Carmol Urea 40%
• Exfoliates as it moisturizes
• May sting
• Primary use by our podiatrist.
Ace Bandages, Gauze, & Packing
Ace Bandages 2”, 3”, 4”, and 6”
Gauze 4x4 Sterile 2x2 Sterile ABD (abdominal pad) Kling- elastic, 3” Kerlix- 4.5” sterile bandage
Packing (emphasis ‘filling’) Plain Packing – ¼”, ½”, 1” – nu-gauze Silver alginate
Wound Care Reference GuidePressure Ulcer Policyguidelines for choices
and application
Consulting Wound Care Nurse
When to call for help: • Notify of ALL new admissions with
pressure ulcers• New onset pressure ulcers• Other wound development, from Stage I• And/or partial, full-thickness wounds
Documentation
Requirements
• Braden Skin assessments are due:• On admission• On transfer (both sending and receiving wards)• On discharge• When there is a change in condition• Daily in acute care and ICU• Weekly in long-term care
Who Can Do Assessments?
• Only RN can do initial assessment in this
VAMC• RN completes CPRS re-assessment with
Sometimes input requested of other nsg
staff members, LPNs, nurse technicians, nurse assistants, & to add care plan
interventions
Which Template Do I Use?
• On admission, use initial skin assessment that is embedded in the Initial Assessment
• Skin Re-Assessment per embedded re-• Assessment template tool• Inpatient wound dressing change:
• Wound assessment/size• Applied care completed
Initial Skin Assessment Template
Part 1 – Braden Scale
Part 2 – Additional Risk Factors
Part 3 – Current Skin Assessment
Skin Problems
Skin Problems - Pressure Ulcer
Pressure Ulcer Stage and Location
102
Pressure Ulcer - Size
Part 4 - Interventions
Interventions
105
CPRS Final Note
Skin Reassessment Template
Part 1 – Braden Scale
Part 2 - Skin Assessment
Skin Problems
Pressure Ulcer Informationfrom Previous Assessment
New Pressure Ulcer
Part 4 - Interventions
To update ALL current interventions must be entered