POLICY TITLE: SKIN CARE ASSESSMENT PREVENTION AND INTERVENTION POLICY Former Policy Title:

Transcription

1 POLICY TITLE: SKIN CARE ASSESSMENT PREVENTION AND POLICY Former Policy Title: POLICY PURPOSE To provide an interdisciplinary, standardized approach to the assessment of skin, prevention of breakdown, and management of wounds. GOALS 1. Identify at risk patients and initiate early interventions for prevention of skin breakdown. 2. Protect against the adverse effects of pressure, shear, friction, and moisture. 3. Reduce the incidence of hospital-acquired pressure ulcers. SCOPE Any licensed or unlicensed professional that has the ability to assess and/or intervene to the patient s Braden risk including personnel from the following areas: - Nursing - Physical Therapy - Occupational Therapy - Nutritional Services - Respiratory - Non licensed staff who will care for patients and document within their scope - All patients at Lancaster General Hospital (Duke Street, WBH) POLICY DETAILS Supportive Data: The skin is the largest organ of the body and therefore is easily affected by all other organ systems. A structured approach to pressure ulcer reduction can be achieved through the use of a risk assessment scale in combination with a comprehensive skin assessment and clinical judgment. Lyder et al (Journal of American Geriatric Society, 2012) found that individuals who developed pressure ulcers were more likely to die during the hospital stay, have generally longer hospital stays, and were more likely to be readmitted than those who did not acquire pressure ulcers. Revision History: 7/30/2015 Page 1 of 23

2 DEFINITION(S) Pressure Ulcer (PU) Community Acquired Pressure Ulcer (CAPU) Hospital Acquired Pressure Ulcer (HAPU) Stage I Stage II Stage III A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Pressure Pressure is the force that is applied vertically or perpendicular to the surface of the skin. Pressure compresses underlying tissue and small blood vessels hindering blood flow and nutrient supply. Tissues become ischemic and are damaged or die. Shear Shear occurs when one layer of tissue slides horizontally over another, deforming adipose and muscle tissue, and disrupting blood flow (e.g., when the head of the bed is raised >30 degrees). Both require pressure exerted by body against bed/chair surface to create the tissue injury. Other location Pressure ulcers can develop on any skin surface subject to excess pressure such as under oxygen tubing, drainage tubing, casts, cervical collars or other medical devices. (NDNQI, 2013) Pressure ulcers that developed prior to hospital admission. The existence of the pressure ulcer(s) was documented on the admission skin assessment or the survey was done on day 1 of the patient s hospital stay and the pressure ulcer was already present. Pressure ulcers that are present on admission (POA) and worsen during the patient s length of stay are still considered community acquired. Must be assessed and documented within 24 hours of admission or PU is considered Hospital Acquired per NDNQI (2013). Hospital acquired refers to new pressure ulcer(s) that developed after admission to your facility. Also termed nosocomial or facility-acquired. The patient s admission record should be reviewed for the documentation of a pressure ulcer. If there is no documentation that the pressure ulcer was present on admission, then the pressure ulcer is counted as hospital acquired. (NDNQI) 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. May be difficult to detect in individuals with dark skin tones. 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 serumfilled blister. Note: This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. 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. Note: The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue. Thus these areas with underlying cartilage structure rarely have pressure ulcers Staged as stage III. In contrast, areas of Revision History: 7/30/2015 Page 2 of 23

3 significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Stage IV Mucosal Pressure Ulcer/ Indeterminable Suspected Deep Tissue Injury (sdti) Unstageable Eschar Incontinence Associated Dermatitis (IAD) Full thickness tissue loss with exposed bone, cartilage, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling Note: Stage IV pressure 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. It is the opinion of NPUAP that cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage IV Statement1.pdf Pressure ulcers found on mucous membranes with a history of a medical device in use at the location of the ulcer. The position of the National Pressure Ulcer Advisory Panel (NPUAP) is that pressure ulcers on mucosal surfaces are not to be staged using the pressure ulcer staging system. It is understood that these ulcers may indeed be due to pressure, however anatomically analogous tissue comparisons cannot be made. Further, it is NPUAP s position that mucosal pressure ulcers not be classified as partial or full thickness, because the clinical assessment of the tissue does not allow the distinction. Therefore, the position of NPUAP is that pressure ulcers on mucous membranes be labeled as mucosal pressure ulcers without a stage identified. (NPUAP, 2012) 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. Note: sdti may be difficult to detect in individuals with dark skin tones, Pain may be the only symptom 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. 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. Black or brown necrotic devitalized tissue; tissue can be loose or firmly adherent, hard, soft, or soggy. (WOCN, 2010) An inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin. (WOCN, 2010). Revision History: 7/30/2015 Page 3 of 23

4 Fungal Infection Intertrigo Inflammation with satellite red or white vesicles (Bryant & Nix, 2012) Mild inflammatory process that occurs on opposing skin surfaces caused by friction and moisture such as groin or axilla (Bryant & Nix, 2012) Definitions obtained from American Nurses Association, NDNQI Data Collection Guidelines (2013) unless otherwise noted. ROLE(S)/REPONSIBILITIES Direct Patient Care Providers Responsible to visually inspect skin integrity during the provision of care and report and document any significant findings to the RN or physician. Registered Nurse Complete and document Braden Risk Assessment Score and head to toe skin assessment within 8 hours of admission, daily, and with any change in condition or transfer of care Activate appropriate clinical practice guidelines based on patient condition and level of Braden risk and additional risk factors Consult Wound Care RN if any (POA) pressure ulcer worsens or progresses to next stage and upon assessment of any newly identified unit acquired pressure ulcer 2 RNs to validate new or changes in pressure ulcers on the off shift and weekends when WOCN not available Collaborate with interdisciplinary team to address early intervention based on Inpatient Wound/Ostomy Certified RN Registered Dietician Occupational Therapy/Physical Therapy Respiratory Therapy Braden subscores and initiate interdisciplinary plan of care Validate nurse findings for POA pressure ulcers stage III, IV, suspected DTI, and unstageable, indeterminable Validate nurse findings for hospital/unit acquired pressure ulcers. See when to consult the inpatient wound/ostomy nurse appendix Collaborate with Registered Nurse and Physician to obtain appropriate nutrition orders for at risk patients Provide nutrition education to at risk patients and their families Collaborate with Registered Nurse to educate patient and family on positioning techniques in bed and in chair for at risk patients Collaborate with Physician and Registered Nurse to determine the need for a seat cushion Assess areas of skin that are in contact with respiratory equipment during routine treatments. Provider Initial Risk Assessment & Reassessment Any licensed professional that has the ability to assess and intervene to the Revision History: 7/30/2015 Page 4 of 23

5 Initial Braden Risk Screen Braden Risk Reassessment patient s Braden risk Initial Braden risk screening will be documented within 8 hours of admission. Braden risk reassessment will be completed daily, with any significant change in condition, or transition in care. PROCEDURE: Assessment Standards Risk Assessment: All patients will be assessed for risk of pressure ulcers and skin breakdown using the Braden Scale, within eight hours of admission, daily, with any significant change in condition, or transfer of department. If the patient has a Braden Score of < 18 launch Pressure Ulcer Risk (Using Braden Scale) (Adult) Note: The Braden Scale for Predicting Risk is a standardized tool used for determining the level of risk for pressure ulcers in adult patients = mild risk = moderate risk = high risk </= 9 = very high risk Appendix A: Braden Scale for Predicting Pressure Sore Risk Skin Assessment: Perform head to toe assessment of skin within 8 hours of admission, daily, with any significant change in condition. On transfer of department the assessment must be documented within 4 hours of transfer. If outside the 4 hours this would be unit acquired and document in Patient Care Summary appropriate skin LDA in Doc Flow sheets. Major Risk Factors for the Development of Pressure Ulcers - General state of health (poor, debilitated, moribund, elderly) - Chronic illness (e.g., diabetes, COPD, immunosuppression) - Poor nutritional state - Immobility due to diagnosis of fractured hip, fractured femur, sepsis, diabetic patient on bed rest, restraints, etc. - Incontinence - Oxygenation/Circulation (peripheral vascular disease, respiratory or circulatory impairment, smoking) - Medications (e.g., corticosteroids, chemotherapy, anticoagulants, sedatives, analgesics) - Altered levels of consciousness (e.g., lethargic, comatose) - Spasticity, contractures - Edema - Peripheral neuropathy - Acute care length of stay greater than or equal to 5 days - Infection/Fever Revision History: 7/30/2015 Page 5 of 23

6 - Diastolic BP less than 60mm Hg - Hemodynamic instability Assess for other extrinsic risk factors: - Review resolved/unresolved pressure ulcer LDA s (Lines/Drains/Airway) for current risk of breakdown - Use of supportive medical devices: nasal cannulas, tubes (ie: nasogastric tubes, foley catheters, fecal management systems, etc), glasses, hearing aids, casts, respiratory mask, immobilizers, ace wraps - Poor hygiene - Undergoing surgery with long operative procedures - Prolonged time on litters - History of skin breakdown/pressure ulcers - Poor dentition - Dysphagia See Appendix D: Device-Related Skin Protection Guide Measuring: What: Bruises, rashes, lesions, ulcers, wounds, reddened areas, skin tears, incision lines How: Length (L) is 12(toward patient s head) to 6 o clock (toward the patient s feet) Width (W) is 3 to 9 o clock Depth (D) is straight 90 degrees down into deepest wound area. To measure the depth of a wound, use a sterile, cotton-tipped applicator Tunneling/Sinus tract- measure longest tract using sterile cotton-tipped applicator, Document tract length and use a clock face to indicate direction of tunneling Undermining measure underlying tissue void at wound edge from ** o clock to ** o clock using sterile cotton-tipped applicator. Document length and use a clock face to indicate direction of tissue void When: On admission, Weekly (Mondays), with any significant changes i.e. debridement, growth, and with initial Negative Pressure wound dressing changes. Documentation for prevention and treatment Pressure Ulcers: Assessments and interventions should be documented in EMR as follows: Prior to initial assessment review Epic documentation under discharge tab, LDA removal for previous documented skin LDA s - Re- launch active LDA s/resolve old LDA s after skin assessment to align with current assessment findings. - If no LDA exists for assessed pressure ulcer then launch a new one. - Documentation on all rows under current LDA s - If Pressure Ulcer Found Launch and initiate Pressure Ulcer CPG and Pressure Risk CPG - Utilize EMR Patient Story to communicate presence of Pressure Ulcers/Wounds on admission, discharge and intradepartmental transfer during Hand-off report. Revision History: 7/30/2015 Page 6 of 23

7 - As part of 24 Hour Chart Check remove any Pressure Ulcer/Wound/Incision LDA that is no longer present on patient in current admission. This can be done by clicking on Discharge tab LDA Removal Remove Now Education: - Using the teach-back method, educate patients, caregivers, and healthcare providers involved in the continuum of care about prevention, treatment and factors contributing to recurrence of pressure ulcers. Evaluate patient/caregiver learning as evidenced by their ability to describe the disease process and prevention/treatment plans, correct demonstration of care, and active participation in the treatment plan. - Document any and all teaching re: wound/pressure ulcer under appropriate education title automatically launched when CPG launched. Additional titles can be added individually as is appropriate. - Utilize Clinical reference tab in EMR to provide Your Care Instruction education sheets to patients and family. Special Populations: The modified Braden Q for Neonates will be the tool used in the NICU. The Braden Q will be used for the risk assessment of infants and pediatric patients up to the age of 8. For patients greater than 8 years old use the Braden Scale for Adults, understanding that in the pediatric population, most pressure injuries are caused by medical devices that the Braden Scale cannot predict. Prevention Interventions for all patients - - Ambulate patient if possible - Make sure knee is supported when elevating lower extremities - Do not use vigorous massage over reddened areas and bony prominences - Limit to one incontinence pad under patient - Cleanse skin after each incontinence episode with non-irritating soaps Note: normal ph of skin is (acidic), choose cleansers lower on the alkaline side, ph balanced, and lipid-based. - Apply clean linen and incontinence pad daily and as needed - Offer to moisturize skin with lotion daily and as needed - Apply skin protectant cream (barrier cream) to skin that is exposed to feces, urine, or moisture; reapply after cleansing - Avoid positioning patient directly on bony prominences - Utilize pressure redistribution surfaces - Consider use of Foam Dressing per criteria listed in Appendix G - Encourage eating and drinking if not contraindicated by Plan of Care - Encourage patient to reposition or assist patient if they are unable to position self. While in bed, repositioning should occur at least every 2 hours. While in chair, repositioning should occur every hour. - Offloading devices for the chair and heels include: Air filled seat cushion/ SAPS Air filled heel protector boots and padded fabric heel protector boots. - Revision History: 7/30/2015 Page 7 of 23

8 - Avoid positioning directly on the trochanter when using the side-lying lateral position - Educate patient, family members, and caregivers on pressure ulcer prevention strategies Interventions based on Braden Subscores 1. Sensory Perception (Score </= 3 implement following interventions) - Teach patient and family importance of turning and positioning - Encourage small frequent changes in position - Use pillows to separate bony prominences - Elevate heels off bed by placing pillow under calf muscle - Instruct/assist patient to change position while in chair or wheelchair - Consider limiting time in chair to one hour or less - Use, positioning pad or mechanical lift to lift/move patient while in bed 2. Moisture (Score </= 3 implement following interventions) - Assess and address cause of moisture - Evaluate type of incontinence, if any (urinary, fecal, or both) and implement toileting schedule or bowel/bladder program when appropriate - Contain any wound drainage using sterile gauze dressing and changing upon moderate saturation (unless specific dressing type and frequency ordered by physician) - Keep skin folds dry - Use incontinence skin barrier cream and absorbent pads as needed to protect and maintain intact skin - Consider fecal management system if skin breakdown is already present and patient is incontinent of stool - Do not use incontinence briefs unless patient is out of bed, going for a test, or going to /participating with physical therapy 3. Activity (Score </= 3 implement following interventions) - Encourage activity as tolerated (Walk patient 3 times/day) - Teach patient and family importance of turning and positioning to prevent pressure ulcers - Elevate heels off bed by placing pillow under calf muscle - Keep head of bed (HOB) at or below 30 degrees unless medically contraindicated to prevent shearing - Instruct/assist patient to change position while in chair or wheelchair - Consider limiting time in chair to one hour or less - Use Under pad or Turning System to lift/move patient while in bed - Consider consult to Physical Therapy/Occupational Therapy - If patient chair-bound consult OT for seating evaluation - Apply Sacral Foam Dressing unless contraindicated per criteria listed in Appendix G 4. Mobility (Score </= 3 implement following interventions) - See Activity interventions Revision History: 7/30/2015 Page 8 of 23

9 5. Nutrition (Score </= 3 implement following interventions)- See Appendix C: Nutrition - Provide tray set up and assistance when - Offer supplements high in protein in addition to usual diet - Consult nutrition for Braden subscore </= 2 and total Braden score of </= 18 - Record % oral intake (doc flow sheet under Nutrition) - Record oral fluid intake (I&O documentation) 6. Friction & Shear (Score </= 2 implement following interventions) - Use absorbent pads if needed to mechanically lift/move patient in bed - Keep HOB at or below 30 degrees unless medically contraindicated to prevent shearing - Consider use of heel/elbow protectors - Reduce pressure created by medical devices, use of foam (See Device Appendix) Skin Care Orders for Nursing **When entering a Per Protocol Cosign order an SBAR will be completed explaining the need for and reasoning behind the order. Order Order Mode Special Instructions Discontinue Use Equipment Specialty Beds Low Air Low Mattress replacement (First Step/ ETS ) Nursing Referral For use treatment of severe moisture related skin breakdown May discontinue low airloss replacement when moisture related skin damage resolves. Low Airloss Bed ( Kinair) Nursing Referral Recent onset paralysis, stage 4 on trunk, post flap graft on trunk, Bariatric Bed Nursing Referral Over 500lbs, or needed for improved bed mobility with large abdominal girth. Air Filled seat cushion Nursing Referral Up to 350lbs- please send home with the patient Air Filled Bariatric Over 350lbs- please Revision History: 7/30/2015 Page 9 of 23

10 seat cushion Turning and Positioning System Seating System Positioning send home with the patient TAPS & SAPS Please send with patient on discharge Heel Protector Boots * Please send heel boots with patient on discharge Order Order Mode Special Instructions Discontinue Use Medications Anti-fungal Treatment: Miconazole Cream with skin barrier (BAZA) Miconazole Creamfor areas that don t need barrier cream, (ears, nose, scalp) For the treatment of yeast in skin folds Topical, BID, apply to affected areas after washing with soap and water, rinsing, and patting dry. Discontinue 7 days after skin looks normal. Nystatin powder for weeping areas above waist line Pressure Ulcer Treatment: Foam Dressing Appendix G: Foam Dressing DimethiconeCream (Hydraguard: blue tube) Topical apply BID) From Pharmacy, per protocol co-sign. For intact or partial thickness wounds including deep tissue injuries, Stage I and Discontinue use when skin is intact. Revision History: 7/30/2015 Page 10 of 23

11 Stage II Pressure ulcers. May also be used on arms and legs for very dry skin. Hydrogel: NSS (Intrasite Gel) Topical, apply BID to affected areas and cover with secondary dressing. PMR/Diet/Nursing PT/OT Seating Consult From Pharmacy, per protocol, co-sign For application on full thickness wounds including Stage III and Stage IV pressure ulcers. New stage IV Pressure Ulcer, Quadriplegic or Paraplegic Nutrition Consult Nursing Referral See Appendix C: Nutrition Discontinue use when skin is intact. Fecal Management System For frequent incontinence of stool creating risk of skin breakdown See Fecal Management System Procedure Strategies for Safe Patient Hand-off Across the Continuum of Care - All surgical/invasive procedural patients are considered at risk for pressure ulcer development and standard pressure ulcer prevention is initiated - Upon intradepartmental transfer (i.e., ED to unit, unit to pre-procedure, preprocedure to post-procedure, post-procedure to unit, etc) the sending RN will communicate to the receiving RN: - Most recent Braden Assessment Score - Any history of previous pressure ulcer - Any current pressure ulcers - Following a surgery/procedure, sending RN will also include in report to receiving RN: - Length of time on the table - Patient positioning during procedure Position Areas at risk for pressure ulcer - Supine - Scapula, occiput, elbows, sacrum, coccyx, heels - Lateral - Ear, acromion process, trochanter, medial Revision History: 7/30/2015 Page 11 of 23

12 (Bryant & Nix, 2012) RELATED DOCUMENTS NPUAP Quick Reference Guide for Prevention NPUAP Quick Reference Guide for Treatment AACN Manual and lateral condyles of the knee, malleolus, foot edge on involved side - Prone/Jackknife Nose, forehead, chest, acromion process, genitalia, breasts, iliac crests, patella, foot edge and toes APPENDICE(S): Reference Guide Appendix A: Braden Scale for Predicting Pressure Sore Risk Appendix B: Skin Care Orders Chart Appendix C: Nutrition Appendix D: Device-Related Skin Protection Guide Appendix E: When to Consult Inpatient Wound Care Nurse Appendix F: Molnlycke Product Guide Appendix G: Foam Dressing REFERENCES American Nurses Association (2013). NDNQI Data Collection Guidelines. Bryant, R. & Nix, D. (2012). Acute & Chronic Wounds (4 th ). Current management concepts. Clinical Practice Guideline: SKIN INTEGRITY IMPAIRMENT, RISK/ACTUAL from CPM Resource Center, Elsevier, v-fall 2011 Clinical Practice Guideline: PRESSURE ULCER RISK (USING BRADEN SCALE) from CPM Resource Center, Elsevier, v-fall 2011 Clinical Practice Guideline: PRESSURE ULCER from CPM Resource Center, Elsevier, v-fall 2011 European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers: quick reference guide. Washington D.C.: National Advisory Panel. Lyder, C. H., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N. R., & Hunt, D. R. (2012). Hospital-Acquired Pressure Ulcers: Results from the National Medicare Patient Safety Monitoring System Study. Journal Of The American Geriatrics Society, 60(9), doi: Revision History: 7/30/2015 Page 12 of 23

13 National Pressure Ulcer Advisory Panel. Pressure Ulcers with Exposed Cartilage are Stage IV Pressure Ulcers: An NPUAP Position Statement Available from: Parslow, N., Barton, P., Harris, C., Harrison, M., Labreche, D., MacLeod, F., et al. (2005). Risk assessment and prevention of pressure ulcers. Registered Nurses' Association of Ontario (RNAO). Retrieved April 10, 2013, from Wound Ostomy and Continence Nurses Society. (2010). Guideline for prevention and management of pressure ulcers. Mount Laurel, NJ: WOCN. Appendix A: Braden Scale for Predicting Pressure Sore Risk Revision History: 7/30/2015 Page 13 of 23

14 Appendix B: Skin Care Order Chart Revision History: 7/30/2015 Page 14 of 23

15 Skin Care Orders for Nursing **When entering a Per Protocol Cosign order an SBAR will be completed explaining the need for and reasoning behind the order. Order Order Mode Special Instructions Discontinue Use Equipment Specialty Beds Low Air Low Mattress replacement (First Step/ ETS) Low Air loss Bed ( Kinair) Nursing Referral Nursing Referral For use treatment of severe moisture related skin breakdown Recent onset paralysis, stage IV on anatomical trunk, post flap graft on anatomical trunk, May discontinue low air loss replacement when moisture related skin damage resolves. Bariatric Bed Nursing Referral Over 500lbs, or needed for improved bed mobility with large abdominal girth. Air Filled seat cushion Nursing Referral Up to 350lbs- please send home with the patient Air Filled Bariatric seat cushion Over 350lbs- please send home with the patient Turning and Positioning System TAPS & SAPS Please send with patient on discharge Seating Positioning System Heel Protector Boots * Please send heel boots with patient on discharge Revision History: 7/30/2015 Page 15 of 23

16 Order Order Mode Special Instructions Discontinue Use Medications Anti-fungal Treatment: Miconazole Cream with skin barrier (BAZA) For the treatment of yeast in skin folds Discontinue 7 days after skin looks normal. Miconazole Cream- for areas that don t need barrier cream, (ears, nose, scalp) Nystatin powder for weeping areas above waist line Topical, BID, apply to affected areas after washing with soap and water, rinsing, and patting dry. Pressure Ulcer Treatment: Foam Dressing Appendix G: Foam Dressing Dimethicone Cream (Hydraguard: blue tube) Topical apply BID) From Pharmacy, per protocol co-sign. For intact or partial thickness wounds including deep tissue injuries, Stage I and Stage II Pressure ulcers. May also be used on arms and legs for very dry skin. Discontinue use when skin is intact. Hydrogel: NSS (Intrasite Gel) Topical, apply BID to affected areas and cover with secondary dressing. PMR/Diet/Nursing PT/OT Seating Consult From Pharmacy, per protocol, co-sign For application on full thickness wounds including Stage III and Stage IV pressure ulcers. New stage IV Pressure Ulcer, Quadriplegic or Paraplegic Nutrition Consult Nursing Referral Appendix C: Nutrition Discontinue use when skin is intact. Fecal Management System For frequent incontinence of stool creating risk of skin breakdown Revision History: 7/30/2015 Page 16 of 23

17 Appendix C: Nutrition See Fecal Management System Procedure Appendix D: Device-Related Skin Protection Guide Revision History: 7/30/2015 Page 17 of 23

18 Clear Liquid Full Liquid Regular Cardiac Low Sodium Diabetic Renal Diet Type Suggested Supplement(s) Resource Breeze High Protein Gelatin Ensure Plus Health Shake* (4oz portion size, good for fluid restriction) Glucerna Shake No added Sugar Health Shake* (4oz portion size, good for fluid restriction) Nepro Renal Shake Type & Cause Location/ Related Signs & Symptoms Interventions Nasal Cannulas: any pressure area not found on admission will be a UAPU Present on admission from oxygen use at home, but not noted on admission will be UAPU Patient pulls tubing too tight to secure Staff applies tubing too tightly or does not reassess tubing every 2 hours and reposition tubing. Eye Glasses: Present on admission from use at home, but not noted on admission will be UAPU Often caused by sleeping with glasses on in hospital because may not know where there is a safe place for their glasses. Posterior ears, upper ears, cheeks, nasal and septum areas May or may not have pain Fungal rash on posterior ears contributing to skin breakdown Bridge of nose Top of ears Sides of temple area May or may not have pain Educate patient not to tighten oxygen tubing Gray ear cushions If no improvement after gray foam intervention consult wound nurses Convert patient to Soft Oxygen tubing Encourage 5 to 10 minute breaks every hour Glasses off for 20 minutes every two hours Glasses off when napping or sleeping at night Gray ear cushions on glass stem pieces Foam over nose if reddened If no improvement after Appearance/ Pressure Damage Reddened skin: blanching Non- blanching: stage I Partial thickness skin breakdown: stage II Full thickness wound with slough: stage III (RARE on Cartilage Nose/ ears) Exposed bone/cartilage : stage IV Unstageable : wound base covered in slough Suspected deep tissue injury: purple or ecchymosis Reddened skin: blanching Non- blanching: stage I Partial thickness skin breakdown: stage II Full thickness wound with slough: stage III (RARE on Cartilage Nose/ ears) Exposed bone/cartilage : stage IV Unstageable : wound base covered in slough Suspected deep tissue Revision History: 7/30/2015 Page 18 of 23

19 Type & Cause Location/ Related Signs & Symptoms C-Pap Masks/ Oxygen Masks, ET Tubes: Present on admission from use at home, but not noted on admission will be UAPU Patient may be pulling at mask to increase friction damage Be careful when patient is on side that mask is not being crushed by bed or pillow. Posterior ears, upper ears, cheeks, nasal and septum areas May or may not have pain Sweating increases risk of skin breakdown because of increase maceration of skin Interventions gray foam intervention consult wound nurses Foam over nose and cheek areas Recommend foam Trach ties with Velcro securement for ears with noted injury or patient pulling on mask May need gray ear foam cushions over elastic support ties on some types of masks If no improvement after interventions consult wound nurses Appearance/ Pressure Damage injury: purple or ecchymosis color Reddened skin: blanching Non- blanching: stage I Partial thickness skin breakdown: stage II Full thickness wound with slough: stage III (RARE on Cartilage Nose/ ears) Exposed bone: stage IV Unstageable : wound base covered in slough Suspected deep tissue injury: purple or ecchymosis color Indeterminable: On mucous Membranes Fecal Management System, catheters, condom catheters: Skin weakened from chronic moisture and enzymatic content of fecal leakage on perirectal skin is more likely to develop skin breakdown Fecal management tubing should be repositioned with each patient repositioning in bed or prevent patient from laying on tube Peri-rectal skin Posterior thighs if patient was laying on tubing Patient may develop yeast rash from increased moisture in area Skin barrier buttocks paste at each repositioning and PRN for leakage events Miconazole with barrier for yeast rash BID for redness, no improvement in 24 hours consult wound nurse Reddened skin: blanching Non- blanching: stage I Partial thickness skin breakdown: stage II Full thickness wound with slough: stage III Exposed bone: stage IV Unstageable : wound base covered in slough Suspected deep tissue injury: purple or ecchymosis color Please also refer to the Fecal Management Rectal Tube CPP. Linens and Lines: Revision History: 7/30/2015 Page 19 of 23

20 Type & Cause Extra linens under patient increase warmth of skin and risk of skin breakdown No bottom sheets are needed for Low Air loss ; negate therapy of air flow bed. Patient laying on tubing: SCD tubing, IV lines, call bells, heart monitors, foley tubing, NG tubing, bath blankets, wrinkled linens, lift pad will create focal pressure areas on the skin. Location/ Related Signs & Symptoms Anywhere under the patient Tubing taped too tightly to skin Casts, braces, ACE wraps, SCDs and TED stockings: When applying the cast or brace over boney prominences pressure areas may develop. Nasal Gastric Tube: When placing NG tube if able place as OG while patient has ET tube and secure to ET tube When placing on nose please do not secure that tube is tight to inner nares Reassess peri tube skin every 2 hours and more Any surface that can have pressure from the brace, ace or cast. May appear as red, purple or a wound when the device is removed. Unexplained pain under the device Patients with diabetic neuropathy, spinal injury or stroke may not have any pain so skin observation is essential for skin protection Inner or upper nares where tube may be resting Assess for moisture in area and patient may need topical like bacitracin ointment to protect skin Interventions Assess carefully with each repositioning of patient that there are no wrinkled, extra linens under patient. Assess carefully that devices are properly positioned. If brace is secured with Velcro assess under brace every 4 hours and prn with pain or swelling TED stockings reassess every 8 hours and prn with pain or swelling Reassess skin under SCD s with each repositioning Access skin every 4 hours under edges of ace wrap and loosen ACE if limb becomes swollen Apply padding with foam dressing at the time of application to known problem areas. Secure to ET tube when unable with Hollister device Reposition NG tube every 8 hours and PRN if any redness Utilize the Hollister NG tube securement device when able. Appearance/ Pressure Damage Reddened skin: blanching Non- blanching: stage I Partial thickness skin breakdown: stage II Full thickness wound with slough: stage III Exposed bone: stage IV Unstageable : wound base covered in slough Suspected deep tissue injury: purple or ecchymosis color Reddened skin: blanching Non- blanching: stage I Partial thickness skin breakdown: stage II Full thickness wound with slough: stage III (RARE on Cartilage Nose/ ears) Exposed bone: stage IV Unstageable : wound base covered in slough Suspected deep tissue injury: purple or ecchymosis color Indeterminable: Known pressure ulcer unable to assess under non-removal brace/cast. Reddened skin: blanching Non- blanching: stage I Partial thickness skin breakdown: stage II Full thickness wound with slough: stage III (RARE on Cartilage Nose/ ears) Exposed bone: stage IV Unstageable : wound base covered in slough Suspected deep tissue injury: purple or Revision History: 7/30/2015 Page 20 of 23

21 Type & Cause frequently if any redness or excessive moisture Please also refer to the GI Tube Management CPP. Location/ Related Signs & Symptoms Interventions Appearance/ Pressure Damage ecchymosis color Indeterminable: On mucous Membranes Appendix E: When to consult the Inpatient Wound- Ostomy Nurse (After your Nursing Wound Care Assessment and Documentation) CONSULT INPATIENT WOUND OSTOMY NURSE Place Consult in Epic Wound Ostomy Inpatient Nurse Consult All Hospital Acquired Pressure Ulcers (ALL Pressure Ulcer with Event reports placed) All patients with an Ostomy All Wound V.A.C.S. or other NPWT Device Any patients on/ordered a Low Air Loss Bed All Pressure Ulcers Stages III and IV, suspected Deep Tissue Injuries, Unstageable Questionable or Advancing Pressure Ulcers CONSULT CLINICAL NURSE EDUCATORS FOR SUPPORT (Does not require a consult to the inpatient Wound Nurses) Questions on Initiating Nursing Interventions from Skin Care Protocol o Yeast o Present on Admission / Healing Pressure Ulcers Stages I and II Patients with wound care orders and Current Physician Management How to apply ostomy wafer Stand by assistance for VAC dressing changes if need support Appendix F: Molnlycke Product Guide Revision History: 7/30/2015 Page 21 of 23

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