Document Title and Code: - Nursing Matters
Wound Management Policy
October 2016
Version 2
Table of Contents
1.0 Policy Statement: 4
2.0 Purpose: 4
3.0 Objectives: 4
4.0 Scope: 4
5.0 Definitions: 4
6.0 Responsibilities. 5
7.0 Assessment and Care Planning Protocol. 6
7.1 Pre Admission Assessment: 6
7.2 Skin Assessment and General Preventative Skin Care. 6
7.3 Skin Care. 8
7.4 Hygiene and Total Emollient Therapy (Penzer and Finch 2001 in HSE, 2007). 8
8.0 Prevention of Pressure Ulcers. 9
8.2 Pressure Ulcer Categories 9
8.3 Risk Factors. 11
8.4 Care Planning to Prevent Pressure Ulcers. 11
8.5 Use of Pressure Relieving Equipment. 11
8.6 Care and Maintenance of Mattresses. 12
8.7 Support Surfaces to Prevent Heel Pressure Ulcers. 12
8.8 Repositioning Technique. 12
8.9 Repositioning for the Seated Resident. 13
8.10 Use Of Support Surfaces To Prevent Pressure Ulcers While Seated. 13
8.11 The Use Of Other Support Surfaces In Pressure Ulcer Prevention 13
8.12 Prevention of Pressure Ulcers Protocol. 14
8.13 Pressure Relieving Equipment Protocol. 15
9.0 Prevention and Management of Skin tears. 16
9.1 Skin Tear Definition. 16
9.2 Risk Factor for Skin Tears. 16
9.3 Care Planning for Skin tears. 16
9.4 Strategies for Prevention of Skin Tears. 17
9.5 Skin tears Classification System (Payne-Martin (1993). 17
10.0 Guidelines for Prevention and Management of Skin Tears. 19
11.0 Wound Management. 20
11.1 Assessment of Wounds. 20
11.2 Assessing exudate. 20
11.3 General Care Planning for Wound Management. 21
11.4 Care Planning for Residents with Pressure Ulcers. 21
11.5 Infected Wounds. 21
11.6 Wound Swabbing. 22
11.7 Infection Control and Wound Dressing. 22
11.8 Practicalities of Asepsis 23
11.9 Clean Technique 23
11.10 Wound Cleansing 23
12.0 Use of Dressings 25
12.3 Recommendations for Dressing Choice in Pressure Ulcers 25
13.0 General Wound Dressing Guide . 28
14.0 Wound Bed Preparation for Chronic Wounds. 30
14.2 Vacuum Assisted Closure (VAC) Therapy. 31
15.0 Management of Leg Ulcers. 32
15.2 Assessment of Leg Ulcers. 32
15.3 Five Key Areas of Leg Ulcer Assessment 32
15.4 Differentiating between Venous and Arterial Leg Ulcers. 33
15.5 Mixed venous / arterial ulcers 33
15.6 Aims of Leg Ulcer Management. 33
15.7 Management of the Resident with a Venous Leg Ulcer. 34
15.8 General Skin Care for Residents with Venous Leg Ulcers (HSE, 2007). 34
15.9 Cleansing Venous Leg Ulcers (Moffat and Harper, 1994 in HSE, 2007). 34
15.10 Management of Arterial leg Ulcers. 35
16.0 Prevention and Management of Diabetic Foot Ulceration. 35
16.1 Assessment for Risk of Diabetic Foot Ulceration. 35
16.2 Prevention of Diabetic Foot Ulceration 36
16.3 Management of A Diabetic Foot Ulcer. 36
17.0 References. 38
|Document Title and Code: |Wound Management Policy / NMA-WMP. |
|Version: |2 |
|Author: |Prepared by Nursing Matters & Associates. |
|Issue Date: |October 2016 |
|Review date: |October 2019 |
|Authorised by: | |
Policy Statement:
It is the policy of the Centre that assessment and care planning for skin care; prevention of pressure ulcers and management of wounds will be underpinned by an evidence based approach based on person centred assessment and care planning.
Purpose:
The purpose of this policy is to promote best practice in skin care and wound management for individual residents in the Centre.
Objectives:
1 To ensure that residents at risk of impaired skin integrity and pressure ulcers are identified and a plan of care developed to meet his /her needs, known wishes and preferences.
2 To provide guidance on skin care and wound management for all staff involved in providing direct care to residents.
3 To outline procedures and practices that must be followed for assessment and care planning related to skin care and wound management.
Scope:
This policy applies to all nursing and healthcare staff who are involved in providing direct care to residents. This policy applies to those wounds commonly seen in a residential care setting for older people such as, pressure ulcers; leg ulcers and diabetic foot ulcers. It does not apply to surgical or traumatic wounds which are usually seen in acute settings.
Definitions:
1 Wound: A wound is defined as a disruption of tissue integrity that is typically associated with a loss of substance. (Sedlarik 2003)
2 A chronic wound: ‘ is one in which the orderly sequence of repair is disrupted at one or several points of the inflammatory, proliferative, re-epithelization, and remodeling stages’ (Sibbald et al, 2000).
3 Pressure Ulcer: refers to ‘a break in the continuity of the skin caused by pressure, friction and shear. This type of damage can also be known as pressure sores, decubiti or decubitus ulcers’ (NICE, 2001).
4 A leg ulcer is defined as a loss of skin below the knee on the leg or foot, which takes more than 6 weeks to heal” (Dale 1983, cited in HSE, 2007).
Responsibilities.
|Actions. |Responsible Person (s) |
|A record of all staff that have read and signed this policy document will be maintained. |Person in Charge (or specify other). |
|Nurses and healthcare staff will be provided with an explanation of the wound management policy as part |Person in Charge (or specify other). |
|of an induction programme. | |
|All nursing and care staff will attend updates on wound management during induction and where there is a|Person in Charge (or specify other). |
|change in practice in this area. | |
|Nurses will maintain their competence in wound management and communicate any knowledge deficits / |All registered nurses. |
|education needs to the Person in Charge or specify other. | |
|Nurses and healthcare staff will sign the policy acknowledgement forms having satisfied themselves that |All nursing and healthcare staff. |
|they understand the contents of this policy document. | |
|Each resident should have an initial screening for the presence or risk of pressure ulcers as part of |Admitting/designated nurse. |
|their admission assessment process and as part of their four monthly reassessment or more frequently if | |
|there is a significant change to their condition. | |
|Any resident admitted with or developing a wound while in the Centre will have an assessment and care |Admitting/designated nurse. |
|plan developed and documented in accordance with this policy. | |
|Any pressure ulcer of grade 2 or more or skin tear will be reported and documented as a clinical |Nurse on duty when pressure ulcer |
|incident using the Centre’s incident reporting form. |identified. |
|Each resident with a risk for or presence of a pressure ulcer will have a care plan as per this policy |Designated nurse in collaboration with the |
|developed in accordance with his/her needs and wishes. |resident’s GP and other healthcare |
| |professionals involved in the residents care|
|Care plans will be developed in collaboration with the resident and /or representative and other |Designated nurse in collaboration with other|
|healthcare professionals involved in the care of the resident. |nurses on duty as well as other healthcare |
| |professionals involved in the resident’s |
| |care. |
|A full assessment of the resident’s needs and wishes will be carried out prior to the use of any |Designated nurse |
|equipment, aids or treatments to prevent and / or manage pressure ulcers. | |
|The use of any equipment / treatment to prevent or manage pressure ulcers will be in accordance with the|Designated nurse |
|requirements for informed consent. | |
|The resident will be monitored for the effectiveness or otherwise of treatments / interventions being |Nursing staff on duty. |
|used to prevent and / or manage pressure ulcer(s). | |
|Residents requiring specialist referrals for the prevention and/or management of a pressure ulcer will |All registered nurses. |
|be referred as appropriate. | |
Assessment and Care Planning Protocol.
1 Pre Admission Assessment:
1 As part of the pre-admission assessment process every prospective resident will be screened for:
The presence of any wounds.
• The presence of any skin conditions.
• Pressure ulcer risks.
1 This information will be obtained from the referring hospital/healthcare facility; the resident and / or the resident’s representative.
2 As part of the general risk assessment on admission, each resident will have a skin assessment and assessment of vulnerability to development of pressure ulcers using both the Centre’s admissions assessment form and the Waterlow / Braden risk assessment.
3 Immobile residents will have a Waterlow / Braden risk assessment within 2 hours of admission and on the first day of admission for mobile residents.
4 Risk assessment should also include clinical judgment.
3 Skin Assessment and General Preventative Skin Care.
1 The Centre’s admission assessment, the Waterlow / Braden assessment and a visual inspection of the resident’s skin should be conducted as part of the resident’s admission assessment on the day of admission or within two hours for immobile residents or those with known risk factors for skin breakdown based on the pre-admission assessment and / or referral letters.
2 A visual inspection of the resident’s skin should be conducted under the following circumstances:
• On admission.
• As part of every risk assessment.
• On-going based on the resident’s degree of risk.
• Prior to the resident’s discharge.
3 The resident’s consent as far as he / she is able should be obtained prior to carrying out a skin assessment. An explanation of how and why a skin assessment is being conducted should be given to the resident prior to commencing any skin assessment.
4 All areas of the resident’s skin should be examined so as to identify any skin lesions and to look for variations in skin quality in different areas of the body. This should be recorded in the Centre’s admission assessment form.
5 When conducting skin assessments, nurses should pay particular attention to sites where skin breakdown occurs most commonly, particularly pressure areas and skin flexures. Early assessment should include examination of bony prominences (sacrum, heels, hips, ankles, and elbows) to identify early signs of pressure damage.
1. Include the following factors in every skin assessment:
• Skin temperature;
• Presence of oedema;
• Change in tissue consistency in relation to surrounding tissue.
6 Where a resident has a dressing, this will be removed so as to complete a wound assessment on the resident.
7 Assisting residents with bathing provides a good opportunity to examine the skin completely.
8 General skin inspection and assessment must include the following:
• Colour – the nurse should observe for variation in colour around the body; also for jaundice (in the skin as well as in the sclera of the eyes), bruising, pallor and inflammation.
• Observation for any specific breaks, sores, ulcers or lesions. Measurements and photographs should be used where possible with the resident’s consent.
• Checking for texture and moisture, such as coarse and / or dry skin.
• Checking for skin turgor by pinching the skin on the forearm or chest. (Decreased turgidity will result in the skin 'tenting', or staying in position when pinched). Decreased turgidity may be due to normal changes in ageing skin but may also indicate the presence of dehydration or malnutrition.
• Checking the temperature of the skin using the back of the hand to identify any localised heat.
• Blanching response.
• Oedema.
• Induration (hardness) of an area of skin.
• Redness of the skin.
• The presence of discomfort or pain that may indicate pressure damage.
2. Use the finger or the disc method to assess whether skin is blanchable or non-blanchable.
• Finger pressure method — a finger is pressed on the erythema for three seconds and blanching is assessed following removal of the finger;
Or
• Transparent disk method — a transparent disk is used to apply pressure equally over an area of erythema and blanching can be observed underneath the disk during its application.
9 A care plan to address the resident’s skin care needs will be developed for residents who have any risk factors for skin breakdown,
10 The care plan must include:
The identification of any risk factors for deterioration in skin integrity / skin breakdown. These can be obtained from the Centre’s assessment form and the Waterlow / Braden score.
Interventions to address risk factors – some of these may be included under other care plans such as when the resident is incontinent or has poor nutritional status.
Any skin care needs related to the resident’s inability to care for their own personal hygiene.
• Skin care needs related to any existing skin conditions.
• Skin care needs related to incontinence.
• When and how often the resident’s skin needs to be inspected.
4 Skin Care.
1 The overall aims of skin care should be to:
• Prevent skin breakdown through promoting effective skin barrier function.
• Promote comfort for the older person.
• Encourage self-management wherever possible.
2 Skin condition and all interventions identified to care for the resident’s skin should be documented in the resident’s care plan and any changes should be recorded and acted upon as soon as they are observed.
3 Excess moisture due to incontinence, perspiration, or wound drainage must be identified and actions documented to eliminate this where possible. When moisture cannot be controlled, interventions that can assist in preventing skin damage should be used.
4 Consideration to the use of barrier creams should be given where residents are incontinent.
5 Skin injury due to friction and shear forces should be minimised through correct positioning, transferring and repositioning techniques.
6 Excessive rubbing over bony prominences must be avoided as this may cause additional damage to skin at risk of developing pressure damage.
7 Following assessment nutritionally compromised individuals should have a plan of appropriate support and/or supplementation that meets individual needs and is consistent with overall goals of therapy. Nutritionally compromised residents must be referred to the dietician in accordance with the Centre’s Nutrition and Hydration Policy.
8 Maintaining activity level, mobility, and range of movement is an important goal of care for residents in accordance with their ability and condition.
9 Soap should be avoided where possible, as it tends to dry the skin further. If soap is to be used, it should ideally be unperfumed and rich in moisturisers.
10 A soap substitute, such as aqueous cream is preferable to soap as it can be applied to the body and rinsed off with water or used on a sponge or flannel. Although this does cleanse adequately, soap can be used if required to wash flexures and groin or particularly dirty areas.
11 Washing water should not be too hot as the heat tends to dry the skin further, but it should be warm enough to be comfortable
12 A no-rinse cleanser, such as Clinisan can be applied during daily care for at least 14 days to reduce the risk of pressure ulcer formation.
13 Emollient soaps are more effective in prevention of skin tears than non-emollient
14 Zinc cream or Sudocrem, if used for at least 14 days can reduce skin redness caused by incontinence in older adult residents in long term care.
5 Hygiene and Total Emollient Therapy (Penzer and Finch 2001 in HSE, 2007).
1 Over washing can be detrimental to the maintenance of healthy skin. Hygiene and total emollient therapy are at the centre of any strategy for promoting good skin health. These strategies improve skin barrier function and comfort and can promote a sense of well-being. Emollient therapy is particularly beneficial for older people. Their skin produces less of the natural oils to protect the outer layer of skin, thus preventing moisture loss and flexibility. Applying emollients helps to mimic the actions of these natural products. Decreasing dryness will also help to reduce itching.
2 Total emollient therapy involves incorporating the use of emollients into the daily care of patients.
There are 3 steps to total emollient therapy:
1. Soap should be avoided where possible
2. Bath oils can be added to wash basin. Care needs to be taken to avoid accidents, as surfaces may be greasy. Water should be warm not hot.
3. After washing the application of a moisturiser helps to maintain the quality of the skin. The moisturiser should be applied by stroking movement in the direction of the hair growth.
Prevention of Pressure Ulcers.
1 Assessment for risk of developing pressure ulcers will be carried out as part of the Centre’s pre admission assessment.
2 Admission assessment for risk of developing pressure ulcers will be carried out within 2 hours of admission for immobile residents and on the first day of admission for mobile residents, or sooner if the pre-admission assessment and / or referral indicates.
3 Assessment for risk of pressure ulcer development will include:
• Completion of the skin condition section in the Centre’s admission assessment form.
• Use of the Waterlow / Braden scale.
• Head to toe skin inspection as detailed above.
• Assessment of risk factors such as previous pressure ulcer, poor nutrition, incontinence, medications through completion of the admission assessment form.
2 Pressure Ulcer Categories
|Category/Stage I: Non-blanchable Erythema |[pic] |
|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. The area may be painful, firm, soft, warmer or | |
|cooler as compared to adjacent tissue. Category/Stage I may be difficult to | |
|detect in individuals with dark skin tones. May indicate “at risk” individuals (a| |
|heralding sign of risk). | |
| |[pic] |
|Category/Stage II: Partial Thickness Skin Loss | |
|Partial thickness loss of dermis presenting as a shallow open ulcer with a red | |
|pink wound bed, without slough. May also present as an intact or open/ruptured | |
|serum filled blister. Presents as a shiny or dry shallow ulcer without slough or | |
|bruising.* This Category/Stage should not be used to describe skin tears, tape | |
|burns, perineal dermatitis, maceration or excoriation. *Bruising indicates | |
|suspected deep tissue injury. | |
| |[pic] |
|Category/Stage III: Full Thickness Skin Loss | |
|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. The depth of a Category/Stage| |
|III pressure ulcer varies by anatomical location. The bridge of the nose, ear, | |
|occiput and malleolus do not have subcutaneous tissue and Category/Stage III | |
|ulcers can be shallow. In contrast, areas of significant adiposity can develop | |
|extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or | |
|directly palpable. | |
|Category/Stage IV: Full Thickness Tissue Loss |[pic] |
|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. The depth of a Category/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. Category/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. | |
| |[pic] |
|Unstageable: Depth Unknown | |
|Full thickness tissue 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. Until enough slough and/or eschar is removed to expose the base of the| |
|wound, the true depth, and therefore Category/Stage, cannot be determined. Stable| |
|(dry, adherent, intact without erythema or fluctuance) eschar on the heels serves| |
|as ‘the body’s natural (biological) cover’ and should not be removed. | |
| |[pic] |
|Suspected Deep Tissue Injury: Depth Unknown | |
|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. 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 thin eschar. | |
|Evolution may be rapid exposing additional layers of tissue even with optimal | |
|treatment. | |
3 Risk Factors.
1 Risk factors for pressure ulcer development in residents include:
• Increased age.
• Obesity or underweight.
• Circulatory conditions affecting skin perfusion and oxygenation.
• Skin moisture from incontinence and sweating.
• Conditions affecting sensory perception such as diabetic neuropathy / peripheral neuropathy.
• Immobility / impaired mobility.
• General health status/condition.
• Friction and shear.
• Use of equipment that applies continuous pressure on a part of the body e.g. oxygen masks.
4 Care Planning to Prevent Pressure Ulcers.
1 Care planning to prevent pressure ulcers must be aimed at minimizing risks and involve the resident as far as he/she is able, the resident’s representative as appropriate and other relevant healthcare professional such as physiotherapist, wound care specialist; dietician and General Practitioner.
2 The care plan therefore will depend on what risk factors are present for each resident, but should include:
• Nutrition care plan where the resident has nutrition / hydration needs.
• Continence care plan for residents with incontinence.
• Scheduled skin inspections.
• Skin care plan if the resident has needs / risks related to maintaining skin integrity.
• Mobility care plan for residents with impaired mobility.
• Re positioning, manual handling and the use of appropriate equipment.
5 Use of Pressure Relieving Equipment.
1 Decisions regarding which pressure relieving device to use is as per pressure relieving equipment protocol (page 14) on the basis of assessment that includes:
➢ Identified level of risk.
➢ Comfort.
➢ Skin assessment.
➢ General health status.
➢ Lifestyle and abilities.
➢ Critical care needs.
➢ Acceptability to resident.
2 All surfaces used by the resident must be considered when deciding on pressure relieving equipment.
3 A 24 hr approach to choosing pressure relieving devices must be implemented for each resident requiring pressure relieving equipment.
4 A schedule for reviewing the resident’s positioning and support surface needs must be documented in the care plan.
5 Pressure relieving devices must be reviewed in response to altered level of risk, condition or needs.
6 Minimum provision devices.
▪ High specification foam mattress.
7 Consider the use of alternating pressure or other high-tech pressure relieving system:
• As a first line preventative strategy for people at elevated risk.
• According to previous history of pressure ulcer prevention and / or clinical condition.
• Where low- tech device has failed.
8 Residents on an alternating pressure or other high-tech pressure relieving system (motorised mattress) should have their required mattress settings documented in their care plan on the nurses assessment and manufacturers guidelines.
9 Settings for individual residents must be checked and recorded daily.
6 Care and Maintenance of Mattresses.
1 Mattresses must be checked by nursing and care staff when changing linen. The mattresses must be checked for any signs of damage or wear to covers; seams; zips and underside staining. Mattresses must be cleaned according to the manufacturer’s instructions between resident use and once weekly for all residents.
7 Support Surfaces to Prevent Heel Pressure Ulcers.
1 Ensure that heels are free of the surface of the bed.
2 Heel protection devices should elevate the heel completely (off load) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The knee should be in slight flexion.
3 Hyperextension of the knee may cause obstruction of the popliteal vein and this could predispose to deep vein thrombosis.
8 Repositioning Technique.
1 Repositioning is aimed at maintaining the resident’s, comfort, dignity and functional ability.
2 Residents must be repositioned in such a way as to relieve or redistribute pressure.
3 The frequency and method for repositioning must be documented in the care plan and communicated to all staff who will be involved in the resident’s personal care.
4 When repositioning a resident, the following must be adhered to and the repositioning schedule must documented in the resident’s care plan:
• Avoid subjecting the skin to pressure and shear.
• Use appropriate lifting aids based on the resident’s individual needs and preferences.
• Never drag a resident when repositioning.
• Always check to ensure the resident is not positioned directly on any tubing, call bell flexes or any medical device/equipment.
• Ensure bedclothes are free of wrinkles, crumbs or anything that could cause pressure to a part of the body.
• Avoid repositioning the resident on any bony prominences that have existing non-blanchable erythema.
• Repositioning should be undertaken using the 30 degree semi Fowler position or the prone position and the 30 degree-tilted side lying position (alternately right side, back, left side) if the individual can tolerate this position and the medical condition allows. Avoid postures that increase pressure, such as the Fowler’s over 30 degree or the 90 degree side lying position, or the semi-recumbent position.
• If sitting in bed is necessary, avoid head of bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx.
9 Repositioning for the Seated Resident.
● Position the resident so as to maintain their full range of activities.
● Select a posture that is acceptable for the resident and minimizes the pressures and shear exerted on the skin and soft tissues.
● Place the feet of the resident on a foot stool or foot rest when the feet do not reach the floor.
● Limit the time a resident spends seated in a chair without pressure relief.
● Use a pillow under the calves to elevate the heels (floating heels).
● Inspect the skin of the heels regularly.
10 Use Of Support Surfaces To Prevent Pressure Ulcers While Seated.
● Use a pressure-redistributing seat cushion for individuals sitting in a chair whose mobility is reduced and who are thus at risk of pressure ulcer development.
● Limit the time an individual spends seated in a chair without pressure relief.
● Give special attention to individuals with spinal cord injury.
11 The Use Of Other Support Surfaces In Pressure Ulcer Prevention
● Avoid use of synthetic sheepskin; cut-out, ring or doughnut type devices; and water-filled gloves.
● Natural sheepskin might assist the prevention of pressure ulcers, but the evidence to support this is not strong.
12 Prevention of Pressure Ulcers Protocol.
13 Pressure Relieving Equipment Protocol.
Prevention and Management of Skin tears.
1 Skin Tear Definition.
“ a traumatic wound occurring principally on the extremities of older adults, as a result of friction alone or shearing and friction forces which separate the epidermis from the dermis (partial thickness wound) or which separate both the epidermis and the dermis from underlying structures (full thickness wound)” (Payne and Martin 1993 and
Coleman, 2001, cited in Templeton, 2003)
2 Risk Factor for Skin Tears.
1 The following have been identified as risk factors for skin tears in the elderly:
• Age and gender.
• History of previous skin tears.
• Dry, fragile skin.
• Medications that thin the skin such as steroids.
• Echymoses (bruising / discolouration of the skin caused by leakage of blood into the subcutaneous tissue as a result of trauma to the underlying blood vessels).
• Impaired mobility or vision.
• Poor nutrition and hydration.
• Cognitive or sensory impairment.
• Co-morbidities that compromise vascularity and skin status, including chronic heart disease, renal failure, cerebral vascular accident.
• Dependence on others for showering, dressing or transferring.
(Stephen-Haynes J, and Carville K., 2011).
2 Resident’s at risk of skin tears should be identified so as to put preventative measures in place. Skin tears can happen as a result of carrying out routine activities such as dressing, bathing, positioning, and transferring.
3 Dependent residents who require total care for all activities of daily living are at greatest risk of developing skin tears; with ambulatory residents at the second highest risk and sight impaired residents in the third category.
(Penzer and Finch, 2001).
3 Care Planning for Skin tears.
1 Where residents are at risk of skin tears, the care plan should identify measures to prevent skin tears.
2 Measures to protect fragile skin from sharp edges during daily activities or care should be documented as per 9.4.
3 Skin care to protect fragile skin should be included in the care plan.
4 Where a resident has a skin tear, the tear should be classified and managed according to wound management guidelines.
4 Strategies for Prevention of Skin Tears.
Promote a safe environment for the resident.
Implement prevention protocol for residents identified as at risk for skin tears.
Consider long sleeves or pants to protect their extremities.
Ensure adequate light to reduce the risk of bumping into furniture or equipment.
Provide a safe area for wandering.
• Protect from self-injury or injury during routine care.
Use transfer techniques that prevent friction or shear.
Pad bedrails, wheelchair arms, and leg supports.
Support dangling arms and legs with pillows or blankets.
Use non adherent dressings on frail skin.
Use gauze wraps, stockinettes, or other wraps to secure dressings rather than tape.
5 Skin Tear Assessment
1 The initial assessment should include a comprehensive assessment of the resident and his/her wound. It is important to determine the resident’s age and medical history, any underlying co-morbidities, general health status and potential for wound healing.
2 The assessment must establish the cause of injury: when, where and how it occurred.
3 In addition, a full assessment of the wound is required to determine the following:
Anatomical location and duration of skin tear.
Dimensions (length, width depth).
Wound bed characteristics and percentage of viable/ non-viable tissue.
Type and amount of exudate.
Presence of bleeding or haematoma.
Degree of flap necrosis n Integrity of surrounding skin.
Signs and symptoms of infection.
Associated pain.
1 The skin tear should then be categorised and all information be carefully documented.
14 Skin tears Classification System (Skin Tear Audit Research (STAR), 2010.).
|[pic] |CATEGORY 1a |
| | |
| |A skin tear where the edges can be realigned to the normal anatomical |
| |position (without undue stretching) and the skin or flap colour is not |
| |pale, dusky or darkened. |
|[pic] |CATEGORY 1b |
| |A skin tear where the edges can be realigned to the normal anatomical |
| |position (without undue stretching) and the skin or flap colour is pale, |
| |dusky or darkened. |
| |CATEGORY 2a |
|[pic] | |
| |A skin tear where the edges cannot be realigned to the normal anatomical |
| |position and the skin or flap colour is not pale, dusky or darkened. |
|[pic] |CATEGORY 2B |
| | |
| |A skin tear where the edges cannot be realigned to the normal anatomical |
| |position and the skin or flap colour is pale, dusky or darkened. |
|[pic] |CATEGORY 3 |
| | |
| |A skin tear where the skin flap is completely absent. |
Source: Stephen-Haynes J, Carville K. Skin Tears Made Easy. Wounds International 2011; 2(4): Available from
15 Properties of an ideal dressing for Skin Tears
Easy to apply.
Provides a protective anti-shear barrier.
Optimises the physiological healing environment (e.g. moisture and bacterial balance, temperature and pH maintenance).
Is flexible and moulds to contours.
Provides secure, but not aggressive retention.
Affords extended wear time.
Does not cause trauma on removal.
Optimises quality of life.
Is cost-effective.
25 Guidelines for Prevention and Management of Skin Tears.
|Prevention |Management |Documentation. |
|* Educate staff on the importance of carefully |If the skin tear flap has dried; it should be removed, |♦ classification/ type of skin tear |
|handling elderly residents with frail skin. Any harsh |using scissors and sterile technique. |♦ location. |
|movement or pulling can create a skin tear. |If the skin flap is viable, gently cleanse area with |♦ size (length, width, depth). |
|* Encourage proper positioning, turning, lifting, and |warm tap water or normal saline and roll the flap back |♦ wound bed condition |
|transferring techniques to prevent friction or shear. |into place using a moistened applicator (cotton bud |Exudate. |
|A sliding sheet should be used to move and turn |etc). |%viable tissue. |
|residents. If the resident is being cared for at home,|Gently clean the skin tear with normal saline. |%non-viable tissue. |
|make sure the resident's family caregivers understand |Let the area air dry or pat dry carefully. |♦ peri wound skin colour and condition |
|these techniques. |Approximate the skin tear flap as close to the wound |(oedema, |
|* Provide padding to bed rails, wheelchair arm and leg|margin as possible. |maceration, induration). |
|supports, and any other equipment that may be utilized|If no undue bleeding, secure flap with |♦ approximation and condition of wound |
|to protect the resident from accidentally bumping into|“Steri-Strips”…sparingly |edges. |
|a hard surface. |If bleeding continues dress with alginate and secondary|♦ pain and its management. |
|* Use pillows and blankets to support arms and legs. |dressing - review in 24 hours. |♦ dressing review in 24hrs. |
|* Recommend that residents wear long sleeves and pants|After securing the flap, manage as you would a skin |♦ any risk factors. |
|for added protection. |graft. The flap should not be disturbed for |♦ approximate dressing removal date. |
|* Use paper tape or a non-adherent dressing on frail |approximately 5 days to allow the skin flap to ‘take’. |♦ expected healing date. |
|skin and gently remove it. Or use stockinette, gauze |Rely on clinical judgment. Use caution if using film |♦ ongoing prevention strategies. |
|wrap, or any other similar type of wrap instead of |dressings as skin damage can occur when removing | |
|tape to secure dressings and drains. |dressings. | |
|* Apply a moisturizing agent to dry skin to keep it |Consider putting an arrow to indicate the direction of | |
|adequately hydrated. Creams are better than lotions. |the skin tear on the dressing to minimize any further | |
|* Provide a well-lit environment to minimize the risk |skin injury during dressing removal. | |
|of residents bumping into equipment or furniture. |Skin sealants, petroleum-based products, and other | |
| |water-resistant product such as protective barrier | |
| |ointments or liquid barriers may be used to protect the| |
| |surrounding skin from wound drainage or dressing/tape | |
| |removal trauma. | |
| |Always assess the size of the skin tear, consider doing| |
| |a wound tracing. | |
| |Document assessment and treatment findings. | |
| |Treat Category 2b and 3 as a full thickness wound | |
Source: Source: Kirckpatrick, M 2004 in Australian Resource Centre for Health Care Innovations; Ayello EA, Sibbald RG., 2008 and Baranoski, S., 2003
Wound Management.
1 Assessment of Wounds.
1 Any resident admitted with or who develops a wound should have a complete assessment of the wound and the assessment documented in the resident’s care plan. Assessment should include:
• Local wound assessment.
• Identification of any risk factors that may affect wound healing.
2 A wound assessment form should be completed and should include:
• Type of wound: pressure ulcer, leg ulcer, skin tear, diabetic foot ulcer.
• Relevant grade of wound if it is a pressure ulcer or skin tear.
• Site of wound: location of the wound can affect healing outcomes.
• Wound measurements – length, width, depth. The size of the wound can be calculated by tracing, use of a ruler, measuring tape, multiplying the width by the length or using photography.
• Incorporating a rule or tape into the photograph will provide a scale. NB written resident consent must be obtained prior to photography being taken.
• To measure wound depth (the distance from the surface to the deepest point) a sterile flexible 6inch (15cm) cotton tipped applicator should be used by grasping the applicator at the point level with the skin and measuring the distance from the applicator tip to fingers. Where depth varies, use the deepest point.
• Clinical appearance of the wound bed – healthy/unhealthy granulation tissue, epithelialisation tissue, sloughly or necrotic tissue or eschar. This should be recorded as a percentage of the wound bed.
• Exudates – colour, type, approximate amount.
• Odour.
• Pain – specify site, frequency and severity.
• Wound edges– oedema, colour, erythema (measure extent), and maceration.
• General condition of surrounding skin – dry, eczema, fragile.
• Colonisation/Infection – suspected, confirmed (specify organisms).
• The resident’s known preferences regarding wound management.
• How the wound is affecting the resident’s general functional ability and quality of life.
2 Assessing exudate.
According to the HSE, 2007:
‘The amount of exudate is assessed based on wound appearance and surrounding skin. Inclusion of the amount of exudate in an assessment is only useful if a clear description is provided. When the wound is dry, there is no exudate. When the tissues are only slightly moist with no exudate in the wound bed, the exudate is described as low. The dressing may only require a change every 4-5 days. When the tissues are wet/saturated and there is exudate in the wound bed, exudate amount is described as moderate. The dressing may require a change every 2-3 days. When tissues are saturated and the wound is bathing in fluid, the exudate is considered to be large. Surrounding skin, if macerated, may be included. A daily dressing is usually required’.
1 A comprehensive resident assessment should include assessment of nutritional status/needs to ensure the resident’s diet can adequately support wound healing.
2 Where the resident has malnutrition, this should be addressed as part of the wound management strategy.
3 General Care Planning for Wound Management.
1 A care plan should be developed in collaboration with the resident and / representative as well as any other healthcare professionals involved in the resident’s care.
2 The care plan should address the need for optimal healing, prevention of complications as well as measures to address causative or contributing factors (see wound management guidelines).
3 The care plan should identify a review schedule and evaluation date.
4 The care plan should be documented and communicated to all relevant nursing and healthcare staff involved in the resident’s care.
5 The care plan should be amended in accordance with the resident’s changing need.
4 Care Planning for Residents with Pressure Ulcers.
1 Residents with pressure ulcers should continue to be assessed for the risk of developing other pressure ulcers as previously outlined.
2 Pressure ulcers should be graded, assessed and managed in accordance with the assessment.
3 A pressure ulcer of grade 2 or more should be reported and documented as a clinical incident.
4 Preventative measure should be put in place to prevent further pressure ulcer development, including positioning, moving and handling, nutrition needs.
5 Vascular assessment may be required where the pressure ulcer is located in the lower extremities, the nurse should liaise with the resident’s attending physician /General Practitioner regarding the need for same.
6 Monitoring of the wound should be conducted at each dressing change and a record of any changes made in the resident’s note.
5 Infected Wounds.
1 Increasing pain and wound breakdown are useful indicators of a wound infection.
2 Treatment for wound infection involves identifying the responsible organism and starting the resident on the appropriate antibiotic / or antimicrobial dressing such as iodine dressings or use of silver dressings.
3 Additional measures for reducing bacterial load include the removal of necrotic tissue and slough, which can harbour bacteria and the control of excess exudate.
4 Topical antibiotics do not hold any place in routine wound management, the risks of toxicity, sensitisation and bacterial resistance far outweigh any potential benefits to the wound.
5 Where a wound infection is suspected, a wound swab should be sent for culture and the nurse should liaise with the resident’s attending physician / GP.
6 Wound Swabbing.
1 The same steps should be taken as prior to any procedure, including explanation of the procedure to the resident and seeking permission to proceed as well as ensuring the comfort and privacy of the resident.
2 Collect the specimen using a sterile technique.
3 Prior to taking a wound swab, the wound should be cleansed with normal saline.
4 The swab should be moistened with normal saline if the wound is dry.
5 The wound swab should be rolled across the prepared area for one full rotation (zigg-zagging can yield excess surface colonisers and affect results, Dow et al, 2003 in Smith and Nephew, 2007).
6 The swab should be immediately placed securely into the transport medium and arrangements made for the transport of the specimen to the laboratory.
7 The wound swab should be accompanied with the appropriate documentation. (Details of resident and details of wound and current treatment). The swab container should also be clearly labelled with the resident’s identification information.
8 The procedure should be documented in the resident’s progress notes.
7 Infection Control and Wound Dressing.
All interventions undertaken in relation to wound care should be performed using an aseptic or clean technique as appropriate following a risk assessment.
1 Aseptic Technique
Aseptic technique is defined as a method that prevents microbial contamination of wounds and other susceptible sites by ensuring that only sterile objects and fluids touch them.
Aseptic technique reduces the risk of contamination to vulnerable sites thus helping to reduce healthcare associated infection.
4 Principles of Asepsis
❖ Prevention of secondary infection of wound during dressing procedure.
❖ Prevention of cross-infection from resident to resident.
❖ Prevention of cross-infection from resident to nurse.
5 The Core Steps that must be taken during an Aseptic Technique include:
❖ All appropriate sterile items are available.
❖ The setting is prepared.
❖ The correct number of staff are available to assist in the process.
❖ The nurse has their relevant personal protective equipment ready for use.
❖ Adequate hand decontamination is performed before commencing.
6 Asepsis can only be achieved if every effort is taken to ensure that;
❖ Standard precautions are employed.
❖ Single-use items are only used once.
❖ Single resident use items are only used for one resident and are decontaminated appropriately in between use.
❖ Re-usable items are decontaminated.
❖ Sterile equipment is stored in a clean, dry area, free from dust and off the floor to protect the integrity of the packaging and the equipment.
8 Practicalities of Asepsis
| |The aim of hand washing is to remove dirt and reduce the skin bacterial load. Antiseptic hand washing is required |
|Hand Washing |prior to an aseptic technique. This aims to remove transient bacteria and therefore prevent them being introduced into|
| |the wound. |
| |Dressing should only be carried out in rooms with adequate hand washing facilities and separate facilities for washing|
|Environment |reusable equipment e.g. bowls for soaking leg ulcers. |
| |Wounds should only be exposed for the minimum amount of time, Use single use medication and dressings per resident. |
| |Foot stools/couch should be washed with neutral detergent & water and dried in between each use. |
| |The purpose of wearing gloves is to protect the hands from becoming contaminated with dirt and micro- organisms and |
|Glove Wearing |prevent the transfer of organisms already present on the skin of hands and to therefore minimise cross-infection. |
| |Sterile gloves are worn for aseptic procedures. |
9 Clean Technique
1 This method is a modified aseptic technique and aims to avoid introducing micro-organisms to a susceptible site and also to prevent cross-infection to residents and staff.
2 A clean technique adopts the same control of infection principles but clean (rather than sterile) single use gloves and/or tap water that is safe to drink may be used.
3 It differs from aseptic technique as the use of sterile equipment and the environment are not as crucial as would be required for asepsis.
4 A risk assessment must first be undertaken by the nurse to ensure the appropriate technique is employed.
5 The process also includes a no or non-touch technique being employed i.e. not handling the ends of sterile items that will come in contact with the site being cared for, and clean single use rather than sterile gloves are advocated.
6 If there is a risk that sterile items may have to be handled, sterile gloves are recommended as in aseptic procedures.
7 Procedures that are appropriate for a clean technique include:
➢ Applying dressings to wounds that are healing by secondary intention e.g. dehisced wounds, leg ulcers, pressure sores or dressings covering tracheotomy site.
➢ Removing drains or sutures.
➢ Endotracheal suction.
10 Wound Cleansing.
1 Consider:
➢ When to clean?
➢ How to clean?
➢ What do I use to clean?
2 When to Clean?
It is not necessary to cleanse wounds at each dressing change and the rationale for doing so should be carefully considered.
If the wound is clean and has minimal exudate, little benefit is derived from routine cleansing which may traumatise delicate new tissue.
Exudate is required on the wound surface to maintain phagocyte levels as well as other wound healing hormones and chemical stimuli. Irrigation would remove these and is therefore best avoided.
It may be necessary to cleanse the surrounding skin to prevent excoriation from excess exudate. This may be achieved by irrigation or wiping around the wound.
7 What do I use to clean?
➢ The use of antiseptics on wounds has been questioned following evidence that they are largely ineffective and have a toxic effect on the micro-circulation that provides oxygen and nutrients to the wound bed.
➢ Saline and chlorhexidine show the least toxicity to healthy cells.
➢ Use sodium chloride 0.9% sterile solution for wound cleansing; if any other solution is used the rationale should be noted.
8 How to Clean?
➢ Saline should be warmed and applied to the wound with a 20ml syringe.
➢ Cotton wool balls are not recommended as fibers may be left in the wound, act as a foreign body and can delay healing.
➢ Bathing/showering is a very effective way of cleansing wounds, i.e. perineal wounds, abdominal wounds, etc.
➢ It is very important to ensure that the bath is clean and dry before and after use. It is recommended that the appropriate disinfectant be used following cleaning e.g. hypochlorite solution is an effective disinfectant in all circumstances, provided that a high standard of physical cleaning of the bath is implemented.
➢ Some residents may present with more complex wound management needs including those who are specifically vulnerable e.g. resident with diabetes. In such circumstances, it is advisable to seek advice from nurse specialists or relevant medical staff.
9 Iodine-Containing Product:
➢ Iodine remains one of the few recommended topical antiseptics.
➢ It is not recommended for the routine treatment of chronic wounds or for those residents who are allergic to iodine.
➢ It may be appropriate to use in selected clinically infected wounds for a limited period - usually maximum of 5 days.
➢ The recommended method of application is the use of already impregnated gauze which is a slow release iodine product that may be used for longer than 5 days - apply according to manufacturer’s’ instructions.
➢ An infected wound should be changed at least daily or according to the manufacturer’s instructions of the product used.
➢ Iodine dressings should be kept to a minimum.
➢ Ensure to read manufacturer’s instructions prior to use.
➢ As iodine can be absorbed through the tissues, it should not be applied if the resident has a thyroid disorder.
➢ Document any pain or adverse reactions when used and reconsider its use.
Use of Dressings
1 The dressing should meet the following criteria:
➢ Maintains a moist environment.
➢ Controls wound exudates, keeping the wound bed moist and protecting surrounding intact skin.
➢ Provides thermal insulation and wound temperature stability.
➢ Protects from contamination of outside micro-organisms.
➢ Maintains integrity and does not leave fibers or foreign substances within the wound.
➢ Does not cause trauma to the wound bed on removal.
➢ Is acceptable to the resident.
➢ Is simple to handle, and economical in cost and time.
2 Dressing choice should be determined by the following factors:
• Type of wound.
• Condition of wound tissue.
• Continence status.
• Known sensitivity to dressings.
• Skin texture.
• Frequent bathing needs.
• Conformability of dressing.
• Absorbency.
• Antibacterial, haemostatic, permeability and odour absorbing properties.
• Ease of use.
• Pain related factors.
• Cost and availability.
2 Adhesive dressings must be avoided on residents with dry or fragile skin, a guaze square should be secured with a bandage or tubigrip with the bandage covering from joint to joint.
3 Recommendations for Dressing Choice in Pressure Ulcers. The European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) make the following recommendations for the use of dressings for Pressure Ulcers.
1 Hydrocolloid Dressings
Examples: Comfeel, Granuflex, Duoderm, Easyderm, Tegasorb
Use hydrocolloid dressings for clean Category/Stage II pressure ulcers in body areas where they will not roll or melt.
← Consider using hydrocolloid dressing on non-infected, shallow Stage III pressure ulcers.
← Change the hydrocolloid dressing if faeces seep beneath the dressing.
← Consider using filler dressings beneath hydrocolloid dressings in deep ulcers to fill in dead space.
← Consider using hydrocolloid dressings to protect body areas at risk for friction injury or risk of injury from tape.
← Carefully remove hydrocolloid dressings on fragile skin to reduce skin trauma.
3 Transparent Film Dressings:
Examples: Opsite; Tegaderm.
← Consider using film dressings to protect body areas at risk for friction injury or risk of injury from tape.
← Consider using film dressings for autolytic debridement when the individual is not immunocompromised.
← Consider using film dressings as a secondary dressing for ulcers treated with alginates or other wound filler that will likely remain in the ulcer bed for an extended period of time (e.g., 3-5 days).
← Carefully remove film dressings on fragile skin to reduce skin trauma.
← Do not use film dressings as the tissue interface layer over moderately to heavily exudating ulcers.
← Do not use film dressings as the cover dressing over enzymatic debriding agents, gels, or ointments.
4 Hydrogel Dressings
Examples: Intrasite Gel, Intraste Conformable.
← Consider the use of hydrogel dressings on shallow, minimally exudating pressure ulcers.
← Consider the use of hydrogel dressings for treatment of dry ulcer beds so that the gel can moisten the ulcer bed.
← Consider the use of hydrogel dressings for painful pressure ulcers.
← Consider the use of hydrogel sheet dressings for pressure ulcers without depth and contours and/or on body areas that are at risk for dressing migration.
← Consider the use of amorphous hydrogel for pressure ulcers with depth and contours and/or on body areas that are at risk for dressing migration.
← Consider the use of amorphous hydrogel for pressure ulcers that are not infected and are granulating.
5 Alginate Dressings
Examples: Kaltostat, Algisite.
← Consider alginate dressings for the treatment of moderately and heavily exudating ulcers.
← Consider alginate dressings in infected pressure ulcers when there is proper concurrent treatment of infection.
← Gently remove the alginate dressing, irrigating it first to ease removal if necessary.
← Consider lengthening the dressing-change interval or changing the type of dressing if the alginate dressing is still dry at the scheduled time for dressing change.
6 Foam Dressings
Examples: Allevyn, Lyofoam.
← Consider using foam dressings on exudative Category/Stage II and shallow Category/Stage III pressure ulcers.
← Avoid using single small pieces of foam in exudating cavity ulcers.
← Consider using foam dressings on painful pressure ulcers. Consider placing foam dressings on body areas and pressure ulcers at risk for shear injury.
← Polymeric Membrane Dressings
← Consider using polymeric membrane dressings for Category/Stage II and shallow Category/Stage III pressure ulcers.
7 Silver-Impregnated Dressings.
Examples: Aquacel AG, Acticoat AG.
← Consider use of silver dressings for pressure ulcers that are infected or heavily colonized.
← Consider use of silver dressings for ulcers at high risk of infection.
← Avoid prolonged use of silver dressings; discontinue when the infection is controlled.
← Consider use of silver sulfadiazine (Silvadene®) in heavily contaminated or infected pressure ulcers until definitive debridement is accomplished.
8 Honey-Impregnated Dressings
← Consider use of dressings impregnated with medical-grade honey for the treatment of Category/Stage II and III pressure ulcers.
9 Cadexomer Iodine Dressings
Example: Iodoflex.
← Consider use of cadexomer iodine dressings in moderately to highly exudating pressure ulcers.
← Avoid use of cadexomer iodine in individuals with iodine sensitivity and in those with thyroid disease.
← Avoid use of cadexomer iodine in large-cavity ulcers that require frequent (daily) dressing changes.
10 Gauze Dressings
← Avoid use of gauze dressings for clean, open pressure ulcers because they are labor-intensive to use, cause pain when removed if dry, and lead to desiccation of viable tissue if they dry.
← When other forms of moisture-retentive dressings are not available, continually moist gauze is preferable to dry gauze.
← Use gauze dressings as the cover dressing to reduce evaporation when the tissue interface layer is moist.
← Use loosely woven gauze for highly exudative ulcers; use tightly woven gauze for minimally exudative ulcers.
← When other forms of moisture-retentive dressing are not available, ulcers with large tissue defects and dead space should be loosely filled with saline-moistened gauze, rather than tightly packed, to avoid creating pressure on the wound bed.
← Change gauze packing frequently to promote absorption of exudate.
← Use a single gauze strip/roll to fill deep ulcers; do not use multiple single gauze dressings, because retained gauze in the ulcer bed can serve as a source of infection.
← Consider using impregnated forms of gauze to prevent evaporation of moisture from continuously moist gauze dressings.
(Gauze dressings today are fairly limited and primarily used as surgical dressings. Due to the need for frequent changes, they have been shown to be costly in professional time. However, the other available topical dressings are expensive and not always in the formulary; therefore, the use of saline-impregnated or moistened gauze to protect the wound is preferable to allowing the ulcer to dry out EUPAP and NPAP, 2009).
11 Silicone Dressings
← Consider using silicone dressings as a wound contact layer to promote atraumatic dressing changes.
← Consider using silicone dressings to prevent tissue injury when the ulcer or periwound tissue is fragile or friable.
12 Collagen Matrix Dressings
← Consider the use of collagen matrix dressings for a non- healing wound.
General Wound Dressing Guide (Source: Naas General Hospital, 2005; East Lancashire Health Economy, 2008).
Wound Bed Preparation for Chronic Wounds.
1 Wound bed preparation is an important step in the management of chronic wounds. The TIME framework is a recognized model that has been developed for wound bed preparation and addresses four essential components. These are:
a) Types of non-viable tissue that may be present, such as necrotic or sloughy tissue that should be removed to promote healing (debridement). The aim is to deliver a fast mode of action to remove non-viable tissue and prevent infection. Methods of debridement include autolytic; enzymatic; biological and sharp surgical debridement. Debridement is indicated for most wounds where nonviable tissue or foreign bodies are present. However there are two exceptions. Pressure ulcers on the heel, which are covered with dry eschar, should not be debrided, nor should dry stable ischaemic wounds until perfusion to the limb has been improved (HSE, 2007).
b) Inflammation and / or infection: The presence of inflammation and / or infection needs to be identified to inform treatment and management. The aim is to deliver a fast reduction in bacteria. Signs and symptoms of infection include
Traditional criteria:
• Abscess.
• Cellulitis.
• Discharge (serous exudate with inflammation; seropurulent; haemopurulent; pus).
Suggested additional criteria:
• Delayed healing (compared with normal rate for site/condition).
• Discolouration.
• Friable granulation tissue that bleeds easily.
• Unexpected pain/tenderness.
• Pocketing at base of wound.
• Bridging of the epithelium or soft tissue.
• Abnormal smell.
• Wound breakdown.
(European Wound Management Association, 2006)
c) Moisture balance is required because too little or too much exudates effects wound healing. The aim is to achieve efficient fluid balance and effective barrier function in the choice of dressings.
d) Edge: Identify edge of the wound that is not advancing or is undermining. Wound size acts as a significant indicator of wound healing. A reduction in wound size of 20%-40% in 2-4 weeks indicates active wound bed preparation and chronic wound closure in 12 weeks in the chronic wound (Smith and Nephew, 2007).
2 Vacuum Assisted Closure (VAC) Therapy.
1 In The Centre, Vacuum Assisted Therapy is initiated and used only by a wound care nurse who has received the appropriate training in the therapy.
2 V.A.C. Therapy, also known as NPWT (Negative Pressure Wound Therapy), is used to create an environment that promotes wound healing by secondary or tertiary (delayed primary) intention. It does this by preparing the wound bed for closure, reducing edema, promoting granulation tissue formation and perfusion, and by removing exudate and infectious material.
3 Indications for Use of VAC.therapy:
• Wounds free from slough or eschar.
• Acute and traumatic wounds.
• Venous or diabetic ulcers.
• Pressure ulcers grades 3 & 4.
• Dehisced surgical wounds.
• Flaps and skin grafts.
• Full-thickness debrided burns.
4 VAC therapy should not be used for any of the following wounds:
• Non-enteric or unexplored fistulae to organs or body cavities.
• Cavity / sinus of unknown depth or origin.
• Wound with malignancy.
• Necrotic wound with eschar or slough.
• Wound with unstable fractures, or sharp / loose fragments of bone.
• Untreated osteomyelitis.
• Actively bleeding wounds.
• Wounds with open joints.
• Wounds with exposed blood vessels or organs.
5 For residents with the following conditions, VAC therapy may only be used in consultation with the resident’s consultant and the Tissue Viability Nurse. The specific guidance / instructions for use must be documented in the resident’s care plan.
a. Enteric fistulae of known origin for closure - ascertain where the fistula goes to and from.
b. Infected wounds – Daily dressings may be required and treatment with systemic antibiotics if appropriate.
c. Residents who are taking anti-coagulants, have haemeostasis problems or a friable wound.
d. Wound near organs or irradiated, sutured or weakened blood vessels.
e. Presence of eschar.
f. Chronic wounds – VAC should only be considered after appropriate modern wound dressings have failed.
Management of Leg Ulcers.
1 Where a resident has a leg ulcer, the nurse should complete a wound care assessment form.
2 The nurse should liaise with the resident’s attending physician / GP regarding the need for specialist assessment and arrange for Doppler.
3 Accurate assessment of leg ulcers is an important prerequisite to effective management.
4 Assessment should differentiate between venous, arterial or ulcers of mixed aetiology.
2 Assessment of Leg Ulcers.
Assessment of leg ulcers should include:
1 Medical History: Past Medical History suggestive of venous or non-venous disease.
2 Physical examination including signs and symptoms of leg ulcers as well as wound assessment.
3 Five Key Areas of Leg Ulcer Assessment (Vowden and Vowden 1998)
|1.The resident |2.The skin |3.The circulation |4.The limb |5.The ulcer |
|History |Colour |Pulses |Oedema |Site |
|Risk factors |Temperature |A.B.P.I. |Shape |Surface |
|Associated diseases |Sensitivity |Capillary return |Mobility of ankle and |Duration |
| | | |resident | |
|Nutrition |Fragility |Ankle flare | |Size |
|Social circumstances | |Varicose veins | |Edge |
| | | | |Infection/pain |
1 Clinical investigations: Investigations to exclude other disorders including; blood pressure, pulse assessment, finger stick blood sugar and blood tests as agreed with the resident’s attending physician/GP.
2 Recording of the Ankle-brachial pressure index (ABPI) using a Doppler. Nurses undertaking a Doppler assessment of the ankle brachial pressure index in residents, must have completed a Category 1 Bord Altranais approved course, in the recording of Ankle Brachial Pressure Index and have achieved competency as measured through clinical assessment. Where no nurse has completed the above training course, the resident should be referred to a tissue viability nurse or the nearest wound clinic for assessment.
3 The nurse should assess, plan, implement and evaluate care in consultation with the resident as far as he/she is able and / or the resident’s representative, and all other healthcare professionals involved in the resident’s care.
4 Differentiating between Venous and Arterial Leg Ulcers.
| |Venous |Arterial |
|Cause |Venous Hypertension secondary to valvular |Poor arterial blood supply |
| |incompetence and calf pump failure. | |
|Site |In the gaiter area, usually near medial |Commonly toes, heels, foot and lateral |
| |malleolus. |aspect of leg. |
|Size |Size variable – develops slowly if untreated|Size variable, develops rapidly. |
|Oedema |Worse at end of day. |Present only if leg is dependent and client |
| | |immobile. |
|Skin |Staining, eczema, atrophe blanche, |Shiny skin: white no elevation, bluish when |
| |indurated, warm to touch. |dependent. Atrophic toenails. Cold to touch.|
|Appearance |Shallow, flat margin, looks healthy, deep |Often deep with loss of the deep fascia, |
| |structures not usually involved. |slough slow to separate. Muscles and tendons|
| | |later exposed. |
|Pain |Pain associated with oedema and bacterial |Very painful, especially at night in bed – |
| |infection – relieved by elevation. |relieved by dependency. |
|Foot Pulses |Present |Reduced or absent. |
|Other History |Deep vein thrombosis: swollen leg, |Intermittent claudication; ischaemic heath |
| |especially after surgery or pregnancy: |disease, hypertension, diabetes mellitus. |
| |phlebitis, varicose veins. | |
5 Mixed venous / arterial ulcers
These will have the features of a venous ulcer in combination with signs of arterial impairment. Where the underlying cause of the ulcers is a combination of chronic venous hypertension and impaired peripheral arterial circulation, it is important to define the predominant factor so that the appropriate treatment may be given. The degree of arterial insufficiency will determine whether it is safe to apply compression and will determine the final regime selected. The exact level of compression depends on the severity of the symptoms and the patient’s ability to tolerate compression bandages.
Source: HSE, 2007.
6 Aims of Leg Ulcer Management.
1 Management and treatment of leg ulcers is aimed at:
• To correct the underlying cause of the ulcer. This normally means improving the resident’s venous and / or arterial circulation in the effected limb.
• To create the optimum local environment at the wound site.
• To improve all the wider factors that might delay healing, especially poor mobility, malnutrition and psychosocial issues.
• To prevent avoidable complications such as wound infection, medicament dermatitis or tissue damage due to over-tight bandaging.
• To maintain healed tissue.
(Morison and Moffat 1994 cited in HSE, 2009)
7 Management of the Resident with a Venous Leg Ulcer.
1 Venous ulcers arise because of venous hypertension. Damaged valves in the deep, superficial and perforating veins are one cause of chronic venous hypertension in the lower limb.
2 Management of venous leg ulcers includes:
• Appropriate Dressing Choice as with general wound care.
• Compression therapy ordered by the resident’s attending physician / GP and carried out by a nurse who is trained in compression therapy or a tissue viability nurse / wound clinic.
• Surgery may be required.
8 General Skin Care for Residents with Venous Leg Ulcers (HSE, 2007).
← The use of ointments instead of creams is advisable, thus reducing the risk of sensitisation.
← Avoid using antiseptics and topical antibiotics.
← Protect skin from elasticated bandages.
← Do not use woollen bandages on dry skin.
← Use appropriate dressings to absorb wound exudates.
← Protect surrounding skin with the application of an appropriate barrier.
← Products containing lanolin or fragrances should be avoided.
← Ideally vinyl gloves should be used instead of latex, especially where rubber allergy is suspected.
9 Cleansing Venous Leg Ulcers (Moffat and Harper, 1994 in HSE, 2007).
← Most leg ulcers are colonised with non-pathogenic organisms, therefore it is not necessary to cleanse leg ulcers using an aseptic technique associated with surgical wounds.
← The leg should be immersed in a plastic bowl, separate to the resident’s basin for personal hygiene, lined with a disposable polythene bag and half filled with lukewarm tap water. This helps to remove debris from the ulcer and the descaling of dry skin. It is also comforting for the patient, especially if the leg has been encased in a multi -layer bandage regime for a week.
← The bowl should be cleaned with detergent and hot water, rinsed and dried thoroughly and stored in an inverted position.
← For resident’s with known infection, the bowl must be cleaned with Oasis Pro20.
← A simple bland non-sensitising emollient to the skin e.g. 50/50 mixture of soft white paraffin and liquid paraffin should be applied following cleansing and drying of the limb. This helps to lift the skin scales that rapidly build up in the leg. Emollients should be applied in downward strokes to prevent folliculitis, taking care to avoid excess application.
10 Management of Arterial leg Ulcers.
1 Residents with vascular disease may require further vascular investigations to assess the extent of the disease. The principles of management are control of the symptoms and observation of the limb for deterioration of either the ulcer or the limb.
2 Pain: Residents should have an assessment of pain and analgesia required prior to dressing changes and throughout the day and night time.
3 Nursing staff should ensure that blood supply to limb is not constricted by avoiding any clothing /stockings / bandages that could constrict the blood supply.
4 Control of oedema: Nursing staff should keep legs elevated when sitting or lying. However, the legs should never be above the level of the heart as this will reduce the effect of gravity on tissue perfusion.
5 Provision of an optimum wound healing environment. However, debridement should be used with caution. If debridement is undertaken in a poorly vascularised foot, the resulting open wound may become infected and lead to greater tissue loss.
6 Infection: The wound should be observed for signs of infection and appropriate steps taken as previously outlined where infection is suspected.
7 Dermatitis: Venous eczema is commonly associated with venous leg ulcers and may have exudates with crusting if skin becomes infected. Frequent emollient application of 50% white / soft paraffin gel should be used. If there is no improvement the nurse should liaise with the resident’s GP to out rule allergic dermatitis and requirements for a short course of topical steroids.
8 The wound should be monitored for any deterioration involving tissue necrosis and the presence of wound infection.
9 Residents should be encouraged to mobilise, to stop smoking, to reduce weight, if overweight and to eat a nutritious diet. They should be advised to prevent further trauma to their limbs.
Compression bandaging should not be used as severe damage to the leg can result in amputation.
Prevention and Management of Diabetic Foot Ulceration.
1 Assessment for Risk of Diabetic Foot Ulceration.
1 As part of the admission assessment, all residents will be screened for current illnesses and health conditions.
2 All residents will have a skin inspection.
3 Where a resident has a history of diabetes, the risk of developing foot ulceration should be determined by the presence of sensation, pulses, skin colour, and temperature and the residents other health conditions.
4 The admitting nurse should liaise with the resident’s general practitioner where he / she has concerns about a resident’s risk for foot ulceration.
2 Prevention of Diabetic Foot Ulceration
1 For residents with normal sensation and no existing foot problems, the care plan should identify the need for correct footwear and checking the residents need for chiropody.
2 Residents who have neuropathy and /or absence of pulse should have a care plan in place to prevent diabetic foot ulceration. This should include a schedule for inspecting the feet at least three monthly; ensuring correct footwear; regular chiropody; skin and nail care.
3 All residents at high risk should be seen every three months by the chiropodist.
4 Resident’s footwear should be properly fitting with no risk of ‘rubbing’ of hard surfaces against the foot by using soft uppers and having no hard or bulky seams.
5 The inside of the shoe should be 1-2cm longer than the foot itself. The internal width should be equal to the width of the foot at the site of the metatarsal phalangeal joints and height should allow enough room for the toes. (HSE, 2009).
6 Socks should be made from cotton or wool and not have any hard or bulky seams or elasticated tops.
7 Wearing socks inside out can prevent rubbing against seams.
8 Dry skin can be treated with aqueous moisturisers, but should not be placed between the toes.
9 Minor cuts or blisters should be covered with a sterile dressing until they heal and if they are slow to heal, the resident’s general practitioner should be informed.
10 Corn plasters should not be used except by a chiropodist.
11 Any signs of swelling, redness, heat or infection should be reported to the nurse on duty and discussed with the resident’s general practitioner.
12 The resident must be advised of the need to wash and dry their feet daily or if they need assistance, this must be documented as part of the resident’s care plan.
13 The resident must be advised not to walk in their bare feet at any time.
14 The temperature of water should be checked for any resident with altered sensation.
15 Care plans should include details of care needs of a resident who is at risk of diabetic foot ulceration, including the above as appropriate.
3 Management of A Diabetic Foot Ulcer.
1 Where a resident develops or has an existing diabetic foot ulcer, the wound should be assessed and the assessment documented.
2 The wound should be cleansed regularly with clean water or saline.
3 Exudate should be controlled in order to maintain a moist wound environment.
4 The admitting nurse should refer to any existing instructions for wound management accompanying the resident on admission.
5 For existing residents, nursing staff should liaise with the resident’s general practitioner and the local wound care specialist to devise a plan of care to manage diabetic foot ulcers.
6 The best evidence supports the use of hydrogels for debridement, although contraindication should be considered, such as infection, excessive exudate, or critical limb ischaemia but other debriding agents may be required and these should be guided by the resident’s general practitioner and wound care specialist.
7 This debridement should not be performed in ischaemic or neuro-ischaemic ulcers without signs of infection.
● Infection in a diabetic foot presents a direct threat to the affected limb and should be
treated promptly and actively. Signs and/or symptoms of infection should be reported and discussed with the resident’s general practitioner as soon as possible.
8 Any resident with an ulcer deeper than subcutaneous tissues should be seen by the general practitioner and hospitalisation must be considered.
References.
An Bord Altranais, (2005) Standards for Nurse Registration Education Programmes. An Bord Altranais. Dublin.
Ayello EA, Sibbald RG. Preventing pressure ulcers and skin tears. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan. p. 403-29
Baranoski, S (2003) How to Prevent and Manage Skin Tears. Advances in Skin and Wound Care. Sept/Oct 2003.
Bank, D and Nix, D (2006) Preventing Skin Tears in a Nursing and Rehabilitation Center: An Interdisciplinary Effort. Vol 2 (9).
1. Coleman, D (2001) Practical Management of Skin Tears. Wound care Network Issue 6.
2. Templeton, S. (2003) Promoting Evidence Based Nursing Practice: Older People and Skin Tears. Issue 16. Royal District Nursing Service, Australia accessed at: [pic][pic][pic][pic]
An Bord Altranais, (2000). Review of Scope of Practice for Nursing and Midwifery. Final Report. An Bord Altranais. Dublin.
CREST, (1998) Guidelines for the Prevention and Management of Pressure Sores. n-i.nhs.uk/crest
NHS Modernising Agency (2003) Essence of care. Resident – focused benchmarks for clinical governance.
National Institute for Clinical Excellence, (2003) Pressure ulcer prevention. .uk
National Institute for Clinical Excellence, (2003) Pressure ulcer prevention. Clinical practice algorithms .uk
NHS Quality Improvement Scotland, (2005). Best Practice Statement: Pressure ulcer prevention
Royal College of Nursing (2001) Pressure ulcer risk assessment and prevention. Royal College of Nursing. London.
Royal College of Nursing and National Institute for Clinical Excellence, (2005) The management of pressure ulcers in primary and secondary care. A Clinical Practice Guideline. Royal College of Nursing. London.
Registered Nurses Association of Ontario (2007) Assessment and Management of Stage 1 to 4 pressure ulcers.
Royal Marsden NHS Trust (2004) Manual of Clinical Nursing Procedures. Blackwell Science, London.
3. Naas General Hospital, (2005) Wound Management Guidelines.
4. Health Service Executive, South Eastern Area, (2007) Wound Management Guidelines.
5. Health Service Executive (2009) National Best Practice and Evidence Based Guidelines for Wound Management.
6. The Dublin Southwest Partnership in Primary Care, Dublin West Community Care and Cherry Orchard Hospital, (2007) Prevention & Treatment of Pressure Ulcers Policy.
7. The Dublin Southwest Partnership in Primary Care, Dublin West Community Care and Cherry Orchard Hospital, (2007) Leg Ulcers Policy.
8. European Wound Management Association (2004) Position Statement on Wound Bed Preparation.
9. European Wound Management Association (2006) Position Statement: Management of Wound Infection.
10. Smith and Nephew (2007) General Wound Management: A pocket Guide for Practice. Smith and Nephew, Dublin.
11. Smith and Nephew (2007) Leg Ulcer Guidelines: A pocket Guide for Practice. Smith and Nephew, Dublin.
12. Stephen-Haynes J, Carville K. Skin tears Made Easy. Wounds International 2011; 2(4): Available from
13. West Essex NHS Primary Care Trust (2007) Wound Management Guidelines and Standard.
14. East Lancashire Health Economy Joint Wound Care Formulary for Primary and Secondary Care 2008.
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Provide resident and or family members verbal/written information about:
▪ Risk factors for developing pressure ulcers.
▪ Skin inspection and care.
▪ Strategies for prevention.
▪ Use and maintenance of pressure relieving devices.
Action to prevent pressure ulcers.
Pressure relieving devices.
▪ Decide which pressure relieving device to use as per pressure relieving equipment protocol on the basis of holistic assessment that includes:
➢ Identified level of risk
➢ Comfort
➢ Skin assessment
➢ General health status
➢ Lifestyle and abilities
➢ Critical care needs
➢ Acceptability to resident.
• Consider all surfaces used by the resident.
▪ Take a 24 hr approach to choosing pressure relieving devices.
▪ Review positioning and support surface needs regularly – document review schedule in care plan.
▪ Change pressure relieving device in response to altered level of risk, condition or needs.
***Use equipment protocol to choose equipment.
Seating
Consider whether sitting time should be restricted to less than 2 hrs. per session.
Seek specialist advice from community O.T. / seating clinic for assessment for aids and equipment and advice on seating positions.
Positioning
▪ Reposition at frequency determined by skin inspection, comfort, ability and general state.
▪ Minimise prolonged pressure on bony prominences
▪ Minimise friction and shear damage – ensure manual handling devices are used correctly
▪ Reposition regularly where a pressure relieving device is used.
▪ [pic]
#%5ACJOEstablish and record a positioning schedule for each individual.
▪ Teach individuals and carers (who are willing and able) how to redistribute weight.
All healthcare staff should have relevant training in:
▪ Pressure ulcer risk assessment and prevention.
▪ Selection and use and maintenance of pressure relieving devices.
▪ Providing education and information for people vulnerable to pressure ulcers.
Document outcome
Carry out a moving and handling assessment.
Record resident’s weight.
Risk assessment using Waterlow / Braden tool.
At risk: Waterlow 10 / Braden 15-16
but
-no history of pressure sore damage
-no erythema over pressure points
-Fully mobile
Nurse on high specification foam mattress.
(NICE, 2003).
Nurse on an alternating low air loss overlay/cushion if resident tolerates.
(Crest, 1998; NICE, 2003)
At risk: Waterlow 10 / Braden 15-16
but
- acutely ill and dependent
- no pressure damage
Nurse on alternating low air loss overlay/cushion.
(CREST, 1998; NICE, 2003).
Moderate / high risk:
Waterlow 15+ / Braden 13 - 14
Nurse on alternating pressure mattress or other high tech pressure redistributing system
(RCN, 2001, NICE, 2003)
High / Very high risk:
Waterlow 20 / Braden >12
Nurse on at least high specification foam mattress/cushion.
(RCN, 2005; NICE, 2005)
Grade 1 or 2 pressure ulcer present but
- reasonable degree of mobility
- moves unaided in bed
Grade 1 or 2 pressure ulcer but
- immobile
- dependent
- deterioration of affected areas
- further pressure ulcer development.
Nurse on alternating pressure mattress replacement or overlay/cushion or low air loss/air fluidised/air flotation system..
(RCN, 2005; NICE, 2005)
Nurse on alternating mattress replacement overlay/cushion or low air loss/air fluidised/air flotation system.
(RCN, 2005; NICE, 2005)
Grade 3 or 4 Ulcer present.
- necrotic tissue.
- Eschar present
Adapted from CREST, 1998;RCN, 2001; RCN, 2005; NICE 2003; NICE, 2005.
[pic]
( Consider if infection present.
[pic]
( Consider if infection present.
[pic]
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