Wound Management
1. PURPOSE
1.1 Identify patients at risk for skin breakdown.
1.2 Reduce or relieve pressure and maintain skin integrity.
1.3 Provide appropriate interventions to manage pressure ulcers and minimize infection.
1.4 Monitor development of/and progress of healing
2. POLICY
2.1 Each patient will have a skin assessment and a treatment plan for the maintenance of skin integrity and
wound management if required.
3. DEFINITION
3.1 Risk assessment - identification of the potential risk that a patient will develop skin breakdown as the result
of pressure to a bony prominence or body part impacted by equipment.
3.2 Skin Inspection - the head to toe evaluation of bony prominences and skin folds / creases when prolonged
pressure may result in skin breakdown.
3.3 Interventions - the steps taken by care providers to increase monitoring, reduce or alleviate pressure,
redistribute weight, and / or eliminate friction and sheer to mitigate or eliminate the risk of skin breakdown.
4. PROCEDURE
4.1 Skin Assessment
4.1.1 The Nurse will:
4.1.1.1 Assess and formulate treatment plan in coordination with the MD
4.1.1.2 Offer bathing within 24 hours of admission to assess skin integrity.
4.1.1.3 Conduct a thorough head-to-toe assessment focusing on skin and bony prominences:
4.1.1.4 Monitor daily if early signs of skin breakdown are present.
4.1.1.5 Document the assessment results.
4.1.1.6 Photograph open areas with consent or if family allows.
4.1.1.7 Complete Braden Scale for Predicting Pressure Sore Risk within 24 hours of admission.
(Appendix 2)
4.1.1.8 Develop interventions to reduce risks and implement interdisciplinary plan of care.
4.1.1.9 Initiate a written plan of care within 24 hours and update as necessary.
4.1.1.10 Complete interdisciplinary team assessments. Document and update quarterly.
4.1.1.11 Evaluate and document resident outcome.
4.2 Preventative Skin Care
4.2.1 The interdisciplinary team will:
4.2.1.1 Identify risk factors for skin breakdown such as:
4.2.1.1.1 Activity
4.2.1.1.2 Cognitive ability
4.2.1.1.3 Impaired mobility
4.2.1.1.4 Poor nutrition
4.2.1.1.5 Decreased sensory perception
4.2.1.1.6 Exposure to excess moisture
4.2.1.1.7 Pain
4.2.2 Develop and implement an interdisciplinary plan of care.
4.2.3 Encourage resident participation in range of motion exercises, seating and positioning program.
4.2.4 Ensure hydration of 1500 ml of fluids/24 hour and monitor weight monthly unless contraindicated
4.2.5 Assess the resident for a bowel and bladder continence
4.2.6 Ensure nails are short and clean. Registered staff must cut the nails of a resident with diabetes.
4.2.7 Schedule 2 baths per week. Avoid using hot water and use a pH balanced, non-sensitizing skin
cleanser. Apply non-sensitizing, pH balanced, lubricating moisturizers and creams with minimal
alcohol content to skin after bathing.
4.2.8 Use protective barriers (e.g., creams, hydrocolloids) or protective padding to reduce friction,
maceration and irritation.
4.2.9 Manage moisture e.g., urine, feces, perspiration, wound exudates, saliva, etc. Use protective barrier
products, change linens and clothing when damp.
4.2.10 Minimize shearing and friction on the skin when cleansing, providing care or moving the resident.
4.2.11 Observe for and respond to resident verbalizations and behaviors indicative of skin discomfort.
4.2.12 Provide and monitor effectiveness of analgesia.
4.2.13 Evaluate, document resident outcome, and update care plan.
4.3 For residents in bed:
4.3.1 Use devices to enable positioning, lifting and transfers e.g., trapeze, transfer board, bed rails.
4.3.2 Reposition dependent resident a minimum of 2 hours during waking, including chair position and a
minimum of 2 times per night.
4.3.3 Relieve pressure from bony prominences:
4.3.3.1 Use devices (e.g., pillows, foam wedges, gel pads, roho cushions).
4.3.3.2 Turn to either side at small increments. Avoid positioning at 90 degrees over the trochanter.
4.3.3.3 Maintain the head of the bed less than 30 degrees.
4.3.3.4 Change angle of reclining chair a minimum of every 2 hours.
4.3.4 Do not use donut type devices or products that localize pressure to other areas.
4.3.5 Use available static air overlay for very high risk residents (Braden Scale < 9) or use a low-air-loss bed
if the resident is at a very high risk, has additional risk factors, uncontrolled pain, or severe pain
exacerbated by turning.
4.3.6 Avoid layers of padding between resident’s skin and relief surface.
4.3.7 Maintain proper body alignment and position of comfort.
4.3.8 Refer to PT for seating assessment and seating devices for special needs.
4.3.9 Develop, implement and update an interdisciplinary plan of care.
4.3.10 Evaluate and document preventative interventions and resident outcomes quarterly.
4.4 Pressure Ulcer/Wound Management
4.4.1 See Appendix 1
5. RESPONSIBILITY:
5.1 IHHC staff:
5.1.1 Comprehensive assessment and evaluation should be done in identifying residents at risk in pressure
ulcer development
5.1.2 Adherence to the policy and application of necessary interventions
5.1.3 To provide education to resident and family members that increases their knowledge on pressure ulcer
risks and encourage participation in the care plan.
6. APPENDICES
6.1 Pressure Ulcer/Wound Management
6.2 Braden Scale Chart (See IHHC/NRSG/FORM/0039-16)
7. REFERENCE
7.1 American Academy of Nurse Practitioners. (AANP). (2007). Standards of practice for nurse practitioners.
Washington, DC: Author
Appendix 1: Wound Management
| Type |
Stages |
Treatment/Dressing |
Frequency |
| Clean, without Cellutlitis |
Type I |
Apply protective dressing, PRN |
As needed |
| |
Type II |
Apply moist dressing such as transparent film |
Once daily |
| |
|
Cleanse the wound |
|
| |
Type III, No Necrotic Tissue |
Apply moist to absorbent dressing, such as hydrogel, foam or alginate |
Twice Daily and/or as prescribed |
| |
|
Consider surgical consultation |
|
| |
|
Cleanse wound |
Every dressing change |
|
Type IV, No Necrotic Tissue |
Apply moist to absorbent dressing, such as hydrogel, foam or alginate |
Twice Daily and/or as prescribed |
| |
|
Consider surgical consultation |
|
| |
|
Cleanse wound |
Every dressing change |
| Magazzini Alimentari Riuniti |
Giovanni Rovelli |
Italy |
Apply moist dressing such as transparent film |
| |
|
Consider surgical consultation |
|
| |
|
Cleanse wound |
Every dressing change |
| |
|
Consider surgical consultation |
|
| Clean Ulcer, with cellulitis |
Local Infection |
Topical antibiotic, apply moist to absorbent dressing |
Twice Daily and/or as prescribed |
| |
|
Cleanse wound |
|
| |
Systemic Infection / advancing Cellullits |
Systemic antibiotic, apply moist to absorbent dressing |
As prescribed |
| |
|
Cleanse wound |
|
| Necrotic Tissue
(Stage III or IV Ulcer)
|
|
Systemic antibiotic |
As prescribed |
| |
|
Surgical Intervention |
|
