Skin Integrity And Wound Management

Introduction

• The wounds we find in today’s Long Term Care facilities are varied and sometimes difficult to close. In addition to the need for the use of evidenced-based best practice guidelines, we as professionals need to be up to date on the accepted techniques for treatment..

• Additionally, we ALWAYS have to follow the guidelines for documentation as found in your Corporate Policy and Procedures.

Admission

Follow your corporate’s policy

regarding the completion of the

admission paperwork

Include a bradenscale assessment

Document all findings in the

appropriate manner

RESIDENT’S RIGHTSAnd Wound Management

Social Security Act Of 1987

• This law requires nursing homes to promote and protect the rights of each resident.

• Strong emphasis is placed on individual dignity and self-determination.

Actions

• Knock on the resident’s door prior to entering the room

• Address the resident by name and introduce yourself

• Assure that the timing of your visit to the resident’s room is convenient for the resident and any visitors present

• Provide for privacy

• Explain the purpose of your visit to the room, asking his/her permission to proceed with the procedure, etc.

What to do next

• Gather the needed supplies

• Review the resident’s order fior treatment

• Wash hands….Always

• Cleanse the bedside table/tray with an antibacterial cleaning wipe and cover with a non-permeable barrier drape

• Place the supplies onto the drape

Remember

Only one wound should be treated at a time. Treat every wound separately.

Next…

• Put on gloves

• Remove the soiled dressing and discard in a plastic bag

• Remove gloves and wash hands

• Open packages of wound supplies on the non-permeable drape/tray

• Replace gloves

• Complete the dressing change

• Change gloves and repeat the process – using a new set up for each additional wound

Remember

• Provide for the resident’s comfort at all times!

• If the resident complains of discomfort, stop the treatment, cover the wound with a cover dressing and follow steps to ensure resident comfort

Wrap up…

• Discard contaminated supplies per infection control policy

• Document procedure on the treatment record

WOUND ASSESSMENTAnd Wound Management

Admission

• Each resident that is admitted to the facility, and re-admitted after a hospital stay, must have a full skin assessment completed within 8 hours of arrival to the facility

Assessment guidelines

• Every nurse should be able to measure and document the presence of skin breakdown

• This includes bruises, rashes and scars, as well as open wounds

Process

• Using the approved assessment tools, determine a resident’s risk level for skin breakdown

• Visualize the skin!! Look in every crack and crevice!

• Document the location of any skin breakdown or scarring

• Determine the etiology of the wound (use the history and physical)

Process

• Document: wound size (in cm), color of tissue (pink, red, yellow ,gray, brown, black), location (use anatomical location terms), stage (if pressure) or thickness (full or partial), and odor

• Document: condition of the periwound (warmth, redness, pain, edema, fluctuance, weeping)

• Document the color, odor and amount of drainage

Process

• Identify s/s of contaminated wounds

• Identify s/s of infected wounds

• Identify s/s of a healing wound

Process

• Staging

• Necrotic tissue

• Full thickness

• Partial thickness

• Arterial

• Venous

• Diabetic

• Burns

• Miscellaneous

Process

• All documentation is to follow your policy and procedure

• Weekly documentation is mandated

Wound Measurement

• Measure in centimeters only

• Use the “clock” method to determine length and width

• Measure the longest point from 12:00 – 6:00, or head to toe to determine length

• Measure the widest point from 3:00-9:00, or side to side to determine width

Wound Measurement (cont’d)

• To determine depth, the base of the wound must be visible

• Use a cotton swab to measure from the base of the wound to the level of the skin surrounding the wound

• Undermining – “skin shelf”

• Tunneling – narrow space extending away from the wound

Questions?And wound management

Skin Integrity and Wound Management_Daybreak_2016_12_22