CENTRAL IOWA HEALTHCARE Marshalltown, Iowa

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1 CENTRAL IOWA HEALTHCARE Marshalltown, Iowa ASSESSMENT OF PATIENTS POLICY & PROCEDURE Policy Number: 3.2 Subject: Purpose: Policy: Assessment And Treatment Of Skin Integrity Identification and treatment of actual or potential skin integrity impairment. All patients presenting for care will have their skin integrity assessed with appropriate actions and plans put into effect. Special Information: 1. Patients admitted to the hospital will have their skin integrity evaluated with each physical assessment and documented in the EMR (electronic medical record). 2. Definitions: Deep Tissue Injury (DTI): Injury to subcutaneous tissue underneath intact skin. This has the appearance of a deep bruise, which may herald the development of Stage III-IV pressure ulcers even with optimal treatment. Staging of pressure ulcers: Stage I: Nonblanchable erythema of intact skin, the beginning of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators. Stage II: Partial thickness skin loss involving epidermis, dermis or both. Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a crater with or without undermining the adjacent tissue. Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (e.g. tendon or joint capsule). 3. Assessment: To identify patient s level of risk: Complete skin assessment and complete Braden scale in the EMR. Assess all pressure points: coccyx, heels, elbows, ears, spine, trochanters, ischial tuberosities, knees, ankles, toes, nose, scapulae and back of head. Document any history of pressure ulcers, slow-healing or non-healing wounds. Assess these other skin characteristics: appearance texture/turgor color & color changes dryness/moisture callous breakdown rashes/irritation warmth/inflammation temperature, etc. 4. Risk factors for Developing Pressure Ulcers A. Decrease in normal sensation or response to discomfort. Including, but not limited to: neuropathy paralysis diabetes

2 dementia degenerative neurological disease cerebrovascular disease CNS injury depression drugs that adversely suppress alertness B. Decrease in mobility. Including, but not limited to: decreased level of alertness post-surgical restrictions neurologic disease/injury fractures pain restraints debilitation C. Impaired nutritional status significant changes in weight (> 5% in 30 days or > 10% in the previous 180 days Albumin < 3.4, PAB < 18.0, Total protein < 6.4.) malnutrition protein, calorie, protein-calorie D. Moisture bowel incontinence diaphoresis bladder incontinence exposure to fluids wound exudate E. Comorbid Conditions: Any other health problems that would adversely affect wound healing or would increase the risk of skin breakdown. F. Braden scale score of 18 or less G. Previous history of slow healing or non-healing wounds or pressure ulcers. 5. Preventive Measures for patients who are at risk of skin breakdown Refer to Addendum Braden Scale Scores and Skin Care Intervention (p. 8) A. Place head of bed at 30 degrees or less. B. Suspend heels. C. Use elbow protectors to reduce friction. These do not provide pressure reduction. D. Use pillows behind back and between knees to pad bony prominences when patient is in sidelying position. E. Use turning schedule; turn every 2 hours or more frequently if patient is unable to relieve pressure or is at higher risk. If in chair, instruct patient to perform weight shifts q 15 min. If indicated, obtain a pressure-reducing cushion for use in chair, recliner or wheel chair. Obtain cushion from materials. F. Use foam to pad between skin and equipment such as oxygen cannula, facemask, tubing, etc. G. Use moisture barrier after each episode of incontinence and with bathing. Protect patient from contact with excessive moisture and fluids. H. PT/OT consult for positioning devices. I. Use a lift sheet to reposition patient in bed. Avoid sliding patient on bed/chair surfaces. J. Do not rub reddened areas. K. If incontinent, provide pericare when needed; apply moisture barrier. Use petrolatum, dimethicone or zinc-based moisture barrier for urinary or fecal incontinence. If patient uses incontinence briefs, leave off in bed and use soaker pad. If brief must be used, leave open in bed to allow airflow to skin. Consider using fecal collection systems if patient has multiple involuntary liquid stools. L. Encourage fluids (240ml every 2h) unless restricted.

3 M. Dietitian consult. Consider offering a medical nutrition supplement. O. Elevate legs above heart to reduce edema when necessary. For open wounds or if Braden Scale score less than 14, above interventions and turn patient every 2 hrs; try for small position changes every 1 hour. Heel ulcers Protect and maintain eschar (dry, dark, tough skin) or blister. Suspend heels with pillows or use other heel protection device. If open or draining wound, cover with gauze and inform physician. Skin Tears Tear with flap - Wash with saline, pat dry, gently pull flap back over wound. Close with steristrips. Dress with non-adherent dressing. Do not use transparent film or telfa. Wrap with roll gauze. Change every 3 days and prn. Date and initial dressing. Tear without flap - Wash with saline, pat dry, dress with non-adherent dressing. Do not use transparent film or telfa. Wrap with roll gauze. Change every 3 days and prn. Date and initial dressing. DO NOT USE TAPE AROUND SKIN TEARS. Minor skin irritation 1. Wash area and pat dry. 2. Apply moisture barrier, such as a Vaseline based product, Zinc-based product, dimethiconebased product, or No Sting barrier wipe. Braden scale will be performed on admission and daily thereafter on day shifts. Repeat sooner if status changes. Skin condition and pressure points will be assessed and documented every shift. Medical Nutrition Therapy: Registered Dietitian will: A. Determine estimated amounts of calories, protein and fluid needed by the patient to facilitate healing. B. Provide appropriate supplements or snacks as needed. C. Make recommendations for vitamin and mineral supplementation. D. Initiate calorie/protein nutrient analysis (calorie count) as appropriate by dietitian or physician. E. Recommend appropriate lab work to assess nutrition risk. F. Consult physician for feasibility of nutrition support if patient is unable to meet nutritional needs orally. 6. Wound Assessment Location- Give detailed description of wound location. Measurements - Measure wound in centimeters. First measure length and width, then depth, then undermining and/or tunneling. In general, envision a clock face on the wound and measure 12 to 6 o clock for length; 3 to 9 o clock for width. Tunneling/Undermining - Undermining is skin overhanging a dead space. Measure in centimeters and record location. Tunneling is a tract or pocket in a wound. Measure in centimeters and record. Probe very gently with cotton swab for measurement. Periwound Skin Describe color and condition of skin around wound. Wound Bed Characteristics Describe color of wound bed and type of tissue seen (yellow, black, pink, adherent, loose, etc.) Exudate - Describe the amount, color and consistency of any wound drainage seen. Odor Document presence of odor and describe. Other Factors Take note of any other factors you detect; eg: wound-related pain, inflammation, warmth, edema, etc.

4 7. Treatment Options A. Assess for pain * Offer medication prior to dressing changes. * Document effectiveness of pain measures. * Remove dressing in least traumatic way possible. Stabilize skin to remove adhesive. Soak adherent dressings with NS prior to removal. B. Dressing Selection: * See Addendum: Dressing Choices. * Transparent film dressing for patients at risk for friction or as a secondary dressing. Change every 3-7 days and prn. Do not use on skin tears or fragile skin. * Hydrocolloid for autolytic debridement and padding. Change every 3-7 days and prn. * Hydrogel wound gel sheet for autolytic debridement, to rehydrate wound, for burns & skin tears. Change every 3-7 days and prn. Will need 2 drsg. Good choice for skin tear. * Amorphous (tube) hydrogel wound gel for autolytic debridement, to rehydrate dry wounds, to ease pain, for burns, and skin tears. Change QD to QOD. Will need 2 dressing. * Foam island dressing for padding, absorption, and moist healing. Use on draining wounds. Not recommended for dry wounds. Change every 3-7 days and prn. * Foam Dressing for padding, absorption, and moist healing. Change every 3-7 days and prn. Secure with gauze wrap or gentle tape. Not recommended for dry wounds. * Alignate or hydrofiber dressing non-adherent absorptive pad. Change when soiled or saturated. Fluff, and gently fill wound. Use cover dressing. Change as ordered and prn. * Moist to moist saline saturated gauze. Fluff, and gently fill wound. Use cover dressing. Change every 4-6 hr and prn. Ask physician for an order to add gel to the moist gauze, then change every 24 hours. C. Wound Dressing Principles * In general: avoid use of peroxide, betadine, acetic acid, and alcohol. These chemicals are toxic to healing cells and interfere with epithelial cell regeneration. * Allow at least one inch of intact skin for tape and adhesive products. * For non-intact surrounding skin do not use strong adhesives or tape. Apply appropriate dressing without adhesive. Cover with large enough cover gauze to allow taping on intact skin or secure some other way. * Do not use occlusive dressings (Hydrocolloid such as Duoderm) in presence of infection. Use moist to moist dressing and notify physician. * Wounds only heal in a moist environment. Keep the surrounding area dry to avoid maceration (white, wet edges) by changing dressing a little more often, using good skin barrier, choosing absorptive product. * If macerated, coat with 3M No Sting Barrier wipe or Vaseline type barrier. * Wounds with depth require filling. For deep wounds, loosely pack with gauze. For small opening, loosely pack with NuGauze or fine mesh qauze. Do not over pack as this causes injury to surrounding tissue. Use cotton swabs or hands to loosely pack rather than metal instruments. * If wound is not healing, re-examine treatment, labs, suggest dietary re-evaluation. May need biopsy for culture. * Dressing changes are a clean procedure, not a sterile procedure. Wash hands. Use gloves. Exceptions include: wounds that are through the fascia, immunocompromised patients, open surgical wounds, or per physician order. D. Notify physician of significant changes in the patient s condition or failure of the treatment plan to prevent or heal wounds. E. Notify the patient s representative (if known) of significant changes in the patient s condition in relation to the development of a pressure ulcer or change in the progression of healing of an existing wound. 8. Documentation

5 1. Upon admission A. Complete skin integrity assessment: integumentary, skin lesions tabs. B. Document Braden Score. Repeat the Braden Scale every day shift and with changes in condition, mobility or moisture (eg. incontinence). C. Document all wounds in daily assessments. D. Photograph, measure and document Stage I, II, III or IV and DTI ulcers, other chronic wounds, and any other areas of concern on admission and weekly. A permit must be signed to photograph the wound. E. Document patient s level of activity up to one week prior to admission including what surfaces the patient has been lying/sitting on. 2. Daily documentation A. Assess wounds and document daily. Document dressing changes. B. Chart any additional information you feel is significant. C. Document pressure point assessment q shift. D. Notify physician of any wounds present. Physician needs to document presence of wounds in order for coding to be accurate and thorough. E. Request referral to wound clinic, if appropriate. F. Photograph, measure, and document stage I, II, III and IV and DPI ulcers or other chronic wounds or with significant changes and at discharge. * Stage II, III & IV Ulcers or other chronic wounds covered by long term dressings (3 or more days) need to be photographed and measured each time dressing is changed. * Place photo in chart on photo record. * Photograph wounds using close-up lens or digital camera with zoom feature. Position a wound measurement device in the photo with the patient s identification and date showing. Label photo with location of wound. G. Document any communication with physicians or patient s representatives that you make regarding wound care.

6 Originated by: Assessment Effective date: 8/93 Authorized by: M/S/P/ICU Director 12/16 Authorized by: Chief Nursing Officer Date Revised date: 9/99, 9/03, 1/05, 11/06, 5/12, 12/16 Review date: 7/10 Distribution: All Nursing Units

7 Assessment and Treatment of Skin Integrity Page 7 Braden Scale for predicting pressure sore risk SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort. MOISTURE degree to which skin is exposed to moisture. ACTIVITY degree of physical activity MOBILITY ability to change and control body position. NUTRITION usual food intake pattern FRICTION AND SHEAR 1. Completely Limited. Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body s surface. 1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 1. Bedfast: Confined to bed. 1. Completely Immobile: Does not make even slight changes in body or extremity position without assistance. 1. Very Poor: Never eats a complete meal. Rarely ears more than 1/3 or any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR is NPO and/or maintained on clear liquids or IV s for more than 5 days. 1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently, slides down in bed or chair, requiring frequently repositioning with maximum assistance. Spacticity, contracture, or agitation leads to almost constant friction. 2. Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR has a sensory impairment which limits the ability to feel pain or discomfort over of body. 2. Very Moist: Skin is often, but not always moist. Linen must be changed at least once a shift. 2. Chair fast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 2. Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 2. Probably Inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding. 2. Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. 3. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort 1 or 2 extremities. 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. 3. Walks Occasionally: Walks occasionally during day, but for very short distances, with or without assistance. 3. Slightly Limited: Makes frequently though slight changed in body or extremity position independently. 3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered. 3. No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. 4. No Impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 4. Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals. 4.Walks Frequently: Walks outside the room at least twice a day and inside room at least once every 3 hours during waking hours. 4. No Limitations: Makes major and frequent changes in position without assistance. 4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplement.

8 Assessment and Treatment of Skin Integrity, Page 8 BRADEN SCALE GUIDELINES AND INTERVENTIONS (recognizing that Braden Scale Scores can range from 6-23 and our trigger is 18) Score Intervention *turn at least every two hours *make turns of 30 degrees *suspend heels *limit sitting to minutes for patient who cannot reposition, otherwise shift every 15 minutes. *begin incontinence management if needed *above interventions plus *keep head of bed 30 degrees or lower *dietitian consult *chair seat cushion when sitting *consider specialty air mattress *vigilant protection from skin moisture due to urinary or fecal incontinence, wound drainage and excessive diaphoresis *above measures plus *change positions every hour with smaller turns, full turns every two hours *consider air mattress Other considerations: -Use good nursing judgment at all times and address individual low scores as needed. Also feel free to implement good skin care interventions at any time even if Braden is > 18. It is never wrong to take preventative measures. -Refer to dietitian. -Involve patient s family in skin protection steps. -Inform other disciplines (P.T./O.T., radiology, etc) of patient s low Braden status and potential for skin injury -Repeat Braden Scores whenever you see a change in patient status (eg: decreasing alertness, increasing pain, change in eating habits, etc.). Don t wait until next day shift.

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10 HEEL PROTECTION DECISION TREE *to order heel protection devices, see below Products available: Pillows, Heelzup Heel Elevating Cushion, Prevalon Boot, Rik Foot Hugger Choose pillows for the following patients: *Braden scores *If proper heel suspension can be maintained with pillows alone Choose the Heelzup Heel Elevating Cushion for the following patients: *Braden Scores 18 or less making them at risk for breakdown *Patients who have limited mobility in bed *Patients who have areas of non-blanching erythema on their heels *Non-orthopedic patients Choose the Prevalon Boot for the following patients: *Orthopedic patients (THR, TKR, Hip fx) *Same indications as above *Patients who cannot or will not keep their feet on a Heelzup cushion *Patients who are accustomed to using a heel lift boot at their residence Remember that the purpose of heel elevation is to prevent the onset of pressure-related damage to the heels, protect recently healed pressure ulcers, and for treatment of pressure wounds that are already present. Heels should still be inspected every shift as part of your assessment. Any areas of non-blanching erythema that are discovered should be protected and monitored. Choosing to use a heel protection device is a decision that can be made by the nurse. Order as a nursing judgment order.

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12 Reference: Mulder, Gerit D., DPM, MS; Jeter, Katherine F., EdE, ET, CETN; Fairchild, Patricia A., RN, BAN, MA, CETN; Clinicians Pocket Guide to Chronic Wound Repair, Wound Healing Publications, 2nd Ed. Pressure Ulcers in Adults: Prediction and Prevention, U.S. Department of Health and Human Services, Publication No Partners in skin care management team, Skin Care Clinical Practice Guidelines Manual, North Iowa Mercy Health Center, Mason City, IA. Preventing Pressure Ulcers, U.S. Department of Health and Human Services, AHCPR Publications No

13 CIH Central Supply Stock Dressing Choices Generic Name Product Name Uses Moisture Barrier Film 3M No sting (spray & wipes) Protection from moisture or adhesive tapes Moisture Barrier Ointment Critic-Aid Clear Clear barrier that adheres to intact and denuded skin Zinc Oxide Moisture Barrier Paste Diaper Ointment (pharmacy item, non perscription) Very thick, used with crusting technique to protect raw skin from stool or urine Wound Gel or Hydrogel Sheet AquaClear Mild hydration for dry wounds, debrides, soothing Wound Gel or Hydrogel Tube Solosite Maximal hydration, debrides, soothing, fills cavities Transparent film TegaDerm Cover, protect, debride Hydrocolloid DuoDerm (thin & thick) Cover, protect, debride, slight absorption Foam with soft silicone technology Mepilex Border & Nonborder Cover, protect, more absorption Hydrofiber Aquacel Most absorptive, packing, gels on contact with exudate. Hydrofiber Aquacel AG Same as plain Aquacel, but is antimicrobial and helps manage wound bioburden T:\Policies\AssessPT\asp3.2r7crk.doc