Bruising or Ecchymosis SKIN TEAR PREVENTION Category I: Skin tear WITHOUT tissue loss Category...
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Transcript of Bruising or Ecchymosis SKIN TEAR PREVENTION Category I: Skin tear WITHOUT tissue loss Category...
Bruising or Ecchymosis
SKIN TEAR PREVENTION
Category I: Skin tear WITHOUT tissue loss
Category II: Skin tear WITH partial tissue loss
Category III: Skin tear with COMPLETE tissue loss, where the
epidermal flab is absent
PARAMETERS OF ASSESSMENT
Prevention is #1 intervention!
Provide a safe environment Perform risk assessment of elderly patients on
admission Implement prevention protocol for patients identified
as AT RISK FOR skin tears and bruising of skin Patients can wear long sleeves or pants to protect
their extremities (if appropriate and applicable) Have adequate light to reduce the risk for bumping
into furniture or equipment Provide a safe area for wandering
STRATEGIES AND INTERVENTIONS
On the correct way of handling patients to PREVENT skin tears
Maintain nutrition and hydration status (if applicable)
Offer fluids between meals (unless contraindicated)
Use lotion, especially on dry skin – arms, legs, BID
Obtain dietary consult (if indicated) – consult with your primary nurse
EDUCATE STAFF OR FAMILY CAREGIVERS
Use a lift sheet (draw sheet) to move and turn patients
Use transfer techniques that prevent friction or shear
Pad bedrails, wheelchair arms, and leg supports
Support dangling arms and legs with pillows or blankets
PROTECT SKIN FROM SELF-INJURY OR INJURY DURING ROUTINE CARE
Use non-adherent dressings on frail skin Apply petroleum-based ointment, steri-strips, or
a moist non adherent wound dressing such as hydrogel dressing with gauze as a secondary dressing (if ordered, indicated and within your scope of practice) telfa type dressings can also be used
If you must use tape, be sure it is made of paper and remove GENTLY. Also, you can apply the tape to hydrocolloid strips placed strategically around the wound rather than directly onto fragile surrounding skin around the skin tear
Use gauze wraps, stockinettes, flexible netting, or other skin protective measures to secure dressing rather than tape
Use no-rinse soapless bathing products (if indicated)
Keep skin from becoming dry, apply moisturizer (if indicated)
PROTECTING SKIN CONTINUED
Gently clean the skin tear with normal saline
Let the area air dry or pat dry carefullyApproximate the skin tear flap (if
indicated)Use caution if using film dressing as
skin damage can occur when removing dressing
Consider marking an arrow on skin tear dressing to indicate the direction of the skin tear to minimize any further skin injury during removal
TREATING SKIN TEARS
When you identify that your patient has bruising and/or skin tears on integument please follow the following protocols:Notify supervisor that a skin tear has occurred by you (via phone)
Notify facility charge nurse (or primary nurse) the occurrence
Fill out incident report form (for QA tracking and trending) and give to supervisor (Joanne)
Document occurrence accurately and thoroughly
AMBERCARE’S REPORTING POLICY
www.hhs.govUS Department of Health and Human Serviceswww.guideline.govwww.ahrq.org
REFERENCES