CONTINUING CARE RESIDENT CARE MANUAL POLICY NUMBER II-C-50 Forms updated December 1, 2014 PAGE 1 OF 1 APPROVED BY: SITE: CATEGORY: Vice President & Senior Operating Officer, Rehab & Continuing Care Edmonton General, Youville Home, St. Joseph s, Lethbridge Nursing Care of the Resident; General The policy will serve as a guide to roles of the interdisciplinary team members and expectations with regard to maintaining skin integrity and wound management practices within Edmonton Continuing Care Centres. It is the responsibility of every individual nursing staff member to assess resident skin integrity and consider skin care a priority. Appropriate procedures will be applied to: promote wound prevention (i.e. retain skin integrity) provide timely assessment of skin eruptions ensure rapid interdisciplinary intervention and ongoing evaluation applying best practice techniques. Efforts to manage the risk of wounds by maintaining current resident function and maximizing their health status should be evident in the day to day care provided in the program. Additional strategies include mobilization, dietary planning, incontinence management, positioning, and pressure reduction/ pressure relief equipment (eg. bed surfaces, wedges, cushions, heel lifts, and bed linen cradles). The Regional Wound Care Guidelines, 2009 are available on every unit as an educational reference and outlines the accountabilities and minimum care standards for Continuing Care Facilities within the Edmonton Zone. Additional or more detailed requirements are outlined in this procedure. CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 1 of 10
CONTINUING CARE RESIDENT CARE MANUAL PROCEDURE NUMBER II-C-50 PAGE 1 OF 8 APPROVED BY: SITE: CATEGORY: Vice President & Senior Operating Officer, Rehab & Continuing Care Edmonton General, Youville Home, St. Joseph s, Lethbridge Nursing Care of the Resident; General I. Interdisciplinary Team Roles Role of the Health Care Aide» Report, Report, Report!!!!!!!!! Understand the risk factors of skin breakdown. Skin assessment of resident should occur on each shift and with regular care and be reported to the LPN/RN/RPN/Manager if there are issues noted. Identify between skin care products and the rationale for each. Monitor dressings-notify the LPN/RN/RPN if dressing is not intact. Role of the LPN Perform Braden Scale on admission, quarterly and as status changes thereafter. Thorough skin assessment of resident upon admission and at regular intervals. Inform the other LPNs/RN/RPN/HCA/Manager when wound is first identified. Document on wound assessment form and in patient care notes when the wound is first observed. Wound care rounds as per protocol. Consult with the Manager/RN/RPN when protocol needs reviewing or changing. CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 2 of 10
NUMBER II-C-50 PAGE 2 OF 8 Role of the Manager Follow-up with the RN/RPNLPN/HCA when skin breakdown is first identified. Consult with the Interdisciplinary Team Members. Inform Physician of Stage 2 wounds or greater. Consult the Wound Team for troubleshooting purposes. Consult with the Community Care Services Wound Care Specialist as appropriate. Perform wound rounds at least weekly and as needed to assess treatment protocol and review treatment goals. Liaise with physician re: sending residents to wound clinic. Role of the Wound Team Act as a consult for problem wounds and will pull in other members of the Wound Team as needed. Review wound management report, collate data and send to the region. Education of new staff during orientation. Provide education for staff on a regular basis. Monthly wound rounds. Role of the Physiotherapist Promoting wound healing through debridement, electrical modalities (i.e. laser). Wound care team member and consult for wound dressing selection. Physical activity and/or exercises to minimize the risk of skin breakdown and/or promote healing; i.e. walking, ROM, exercises. Bed mobility - techniques, tips and strengthening routines. Gait assessment, re-education, balance training and fall prevention. Equipment related to transfers, bed mobility and ambulation i.e. trapeze- bars, loaner walkers. Specific transfer techniques to minimize friction and shear. Assessment of causes and education on environmental factors and prevention. Role of the Clinical Dietitian Assess the nutritional need of the residents to promote wound healing. Adjust the resident meal plan to achieve individual goals; i.e. increasing protein intake. Suggest nutrient supplementation when appropriate. CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 3 of 10
NUMBER II-C-50 PAGE 3 OF 8 Role of the Occupational Therapist Provide consultation on: o bed mobility and positioning issues; o seating concerns (chair, wheelchair, bed); o performance of activities of daily living (ADL's) when an individual has or is at risk for skin breakdown; o transfer techniques and equipment; and o equipment/products related to the above, wound offloading aids/device. Assessment and prescription of pressure garments. Recommendations and fabrication of the appropriate footwear or shoe orthotics. II. General Information 1. Refer to flowsheet. 2. On each unit, a Unit Wound Care Binder contains the current wound progress notes, individual wound care protocol/s, Braden scores and the Monthly Report. (Braden Scores are completed and entered into the Minimum Data Set on admission, quarterly and with changes of status.) As the documentation is completed, or as wounds are healed, the documents are filed in the respective resident clinical health record. 3. Refer to the Wound Care Guidelines 2009 for information on skin and wound care products. CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 4 of 10
NUMBER II-C-50 PAGE 4 OF 8 4. Pressure Ulcer Reduction and Relief Factors that lower capillary blood flow include low blood pressure, poor circulatory status, poor nutritional status, poor skin condition, weight, fluid intake, and body temperature. A pressure reducing device refers to its ability to significantly reduce the interface pressure (between the skin and surface), but not consistently below capillary closure. A pressure relieving device consistently reduces interface pressures below capillary closure pressure. Sustained pressure in excess of capillary closure will result in ischemia and, over time, necrosis in the underlying tissue. A referral to the Occupational Therapist and Physiotherapist should be made for assessment. The Manager/RN/RPN is informed by the unit nursing staff of all new open areas or changes in skin condition. Resident repositioning is necessary every two hours for unrestrained residents (eg. sitting in a wheelchair or bed-ridden). Residents who are restrained should be repositioned every hour. Turning schedules are required even when special surfaces are in place. Special surfaces may be available on transfer to the facility through transfer orders and arrangements through Central Assessment and Placement, Administrative Support. Also, for residents already residing in continuing care, specialty surfaces can be arranged by completing a Braden Assessment as well as other forms attached to this procedure and contact with the zone Wound Specialist at Community Care Services, 780-735-3325. The Wound Team and or unit Occupational Therapist should also be consulted for assistance within the facility. To place the order through Hill-Rom Canada, the office is 1-800-267-2337 or the website is www.hill-rom.com. Wedges are recommended to offset the weight. Other aids include trapeze bars, sliding sheets, repositioning slings, and floating heel devices. CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 5 of 10
NUMBER II-C-50 PAGE 5 OF 8 5. Wound Treatments Basic dressing supplies are renewed on the unit supply carts according to an inventory list. Products are also ordered from Stores or as special orders. Contact the Wound Team/Manager for supply lists and product information. The Wound Team will maintain a small stock of supplies to be trialed and used until stock is available or until the protocol is known to be an appropriate treatment for the resident. Debridement methods include surgical, enzymatic, autolytic and mechanical (refer to the Regional Wound Care Guidelines for authorization guidelines and special education requirements). Dry eschar may be left intact if no drainage is present. Dressing selection is outlined in a protocol that is reviewed weekly unless changes which warrant a protocol change are reported to the Manager/RN/RPN. The LPN is not to deviate from the outlined protocol without first consulting with the Manager/RN/RPN/Wound Team. CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 6 of 10
NUMBER II-C-50 PAGE 6 OF 8 6. Documentation Wound Description Location, size, depth (could use photography, Visitrak where applicable, cellophane tracings) Stage of the pressure ulcer Condition of wound bed-color (red, yellow, black) or presence of granulation, eschar, slough, drainage Edges-regular or irregular, presence of induration, undermining or tracking Surrounding tissues-induration, fever, erythema, edema Odor Pain Lower Extremity Wounds (If the wound involves a lower extremity, the following should be added to the above list) Describe condition of nails Document pedal pulses, Ankle Brachial Index (ABI) and toe pressures Edema, staining of surrounding tissues, varicosities, pain Debridement Wound treatment should be documented on a regular basis and include: Treatment procedure and/or dressing product choice Response of wound to product Recommended frequency of treatment/dressing product changes Indications for change of product and reassessment. Response of the individual to the treatment (eg. tolerated procedure well). Refer to Documentation sheets (attached): Continuing Care Wound Assessment & Treatment Record 2009 Monthly Report 2009 Braden Pressure Ulcer Risk Assessment scale III. CONSULTATION 1. A referral for consultation by the Wound Team and or the Community Care Services Wound Specialist (see Appendix for referral and follow-up forms) and or an Acute Care Wound Clinic is appropriate according to the following criteria: CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 7 of 10
NUMBER II-C-50 PAGE 7 OF 8 A Braden Pressure Ulcer Risk Assessment has been performed and there has been no response to treatment. A referral to the Occupational Therapist and Physiotherapist has been made for further assessment and there is a request for additional assistance for the resident. Where appropriate, an ABI has been done. An ABI which is less than 0.8 or greater than 1.2 requires a vascular assessment. (Urgent referral to a vascular surgeon is needed if ABI is less than 0.6.) Dermatitis (non-healing) is present. Sepsis is present. A necrotic wound is present. 2. Wound Care Assessments and Consultation Teams The Manager is informed by the unit nursing staff of all new open areas or changes in skin condition. At least weekly, the Manager or designate is required to view the current wounds on the unit. The Manager is encouraged to involve all levels of unit nursing staff, and the interdisciplinary unit team; i.e., PT, dietician. The pharmacist may be informed and recreational therapists may adapt activities. A comprehensive team approach is the best practice model for wound care. The attending physician should be updated and involved in the treatment protocol. Individuals with a recurrent ulceration should be referred to a Physiotherapist, Occupational Therapist as appropriate or to a Dietician for assessment and consultation. The Wound Care Team also provides support by wound rounds, individual consultations and follow up. The team may be comprised of the RN/RPN/Educator, the Occupational Therapist, and the Physiotherapist and other members of the interdisciplinary team as appropriate. CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 8 of 10
NUMBER II-C-50 PAGE 8 OF 8 This team provides consultation on healing, product recommendations and assists the Manager or designate to outline the dressing protocols. (At the EGCCC, a wound measurement device is available (Visitrak) through this team). Pictures are taken for baseline purposes and approximately every two weeks following, with the appropriate consent from the resident and or agent. Further expertise and consultation may be sought from the Regional Acute Care Wound Clinics at the RAH and MCH or the zone Community Care Services Wound Specialist. When a resident returns from the wound clinic or when the resident has been seen by the Wound Specialist, and has a specific wound care protocol recommended,, the recommendations should be discussed with the attending physician and an order written to follow the clinical protocol suggested. 3. Additional resources to consider are the following: Referrals for Consultation: Dietitian Enterostomal Therapist Nurse Practitioner Clinical Nurse Specialist Infection Control Practitioner Occupational Therapist Physiotherapist Dermatologist Diabetologist Plastic Surgeon Vascular Surgeon Respiratory Therapist (Hyperbaric Oxygen Unit) CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 9 of 10
Flow Sheet Breakdown in skin Integrity Identified by Care Provider Notify Manager/RN/RPN and document in Patient Care Notes Manager/RN/RPN to assess resident Consult Physician when stage 2 wound exists LPN/ Manager/RN/RPN to do Braden Scale Consults to O.T, P.T, Dietician, Wound Care Team, if necessary Develop Wound Management Protocol Refer to Regional Wound Care Guidelines Document on wound assessment form. Place form in wound care binder. Document in Patient care notes and Wound Tracking Form. Manager/RN/RPN to review wound weekly Manager/RN/RPN to follow Protocol Is wound healing? Yes Document on wound assessment form and in patient care notes No Notify Manager/RN/RPN regarding assessment by Wound Care Team. Consult to wound specialist or wound clinic if necessary. CCPOLICY/11-C-50/RESIDENTCARE/WOUNDMANAGEMENT Page 10 of 10
Wound Assessment and Treatment Record WOUND NUMBER OF Location: Date of Onset: Wound resolved (date): WOUND TYPE Initial Pressure Ulcer Stage: Arterial Ulcer Acute Wound/Trauma Venous Stasis Ulcer Neuropathic Ulcer Malignant Wound Fistula Skin Tear Surgical Wound Other: Allergy/Sensitivity: History of Current Problem: Cause Check if applicable: Diabetic Palliative care pathway Lower limb Assessment * (Date completed): Assessment (recommended with each dressing change) Date: CURRENT PRESSURE WOUND STAGE/ DEPTH (other wounds) I. Reddened (non-blanchable intact skin) II. Partial thickness loss of dermis(shallow ulcer, blister, abrasion) III. Full thickness involving subcutaneous tissue IV. Full thickness exposing muscle/bone/tendon N. Unknown depth wound bed covered with slough &/or eschar Suspected deep tissue injury Purple or maroon, boggy/firm, painful WOUND BED COLOR (% of wound bed) Red Pink Yellow Black EXUDATE Exudate Amount None = N Scant = SC (no drainage, wound moist) Small = SM <25% Moderate = M 25-75% Large = L >75% Exudate Color Serous = S (clear yellow) Green = G Yellow = Y Tan = T Red = R (bloody) Sero-Sanguineous = SS (clear pink) ODOR (following cleansing) (circle appropriate response) PERI-WOUND SKIN (around wound) Healthy/Intact = 1 Erythema = 2 Macerated (waterlogged)= 3 Edema = 4 Dry/ Crusty = 5 WOUND MEASUREMENT TUNNELLING -circle Yes /No. UNDERMINING -circle Yes /No. (Indicate Tunnelling with an arrow on the clock face) (Indicate Undermining with shading on the clock face) Warm to touch = 6 Cool to touch= 7 Satellite lesions = 8 Indurated (hard) =9 Other* Length (cm) x Width (cm) x Depth (cm) PAIN (Rate on a scale of 0 10 when possible otherwise yes/no) PHOTO STAFF INITIAL * See Clinical Notes Wound Assessment and Treatment Record Revised November 2014 Page 1 of 2
Wound Assessment and Treatment Record Frequency of Dressing change: 1 2 3 4 5 Goal: WOUND TREATMENT PROTOCOL Signature and designation: Date: REVISED WOUND TREATMENT PROTOCOL Frequency of Dressing change: 1 2 3 4 5 Goal: Signature and designation: Date: R L R L Frequency of Dressing change: 1 2 3 4 5 Goal: REVISED WOUND TREATMENT PROTOCOL R L Signature and designation: Date: DRESSING CHANGE Date Time Signature and Designation Wound Assessment and Treatment Record Revised November 2014 Page 2 of 2
Wound Assessment and Treatment Record PHOTO RECORD Comments: Date: Signature: Name and Designation: Comments: Date: Signature: Name and Designation: Comments: Date: Signature: Name and Designation: Comments: Date: Signature: Name and Designation: Wound Assessment and Treatment Record Revised November 2014 Page 3 of 2
Wound Assessment and Treatment Record Guidelines for completion: General One treatment record is utilized for each wound. Note some residents may have more than one treatment record in progress. Note: Place an asterisk (*) in any box to indicate that incidental charting has been provided in the clinical notes. Wound number Note wound number ie. 1 of 4 if resident has four wounds. Wound type: Check the appropriate wound type. Specify type of wound if you check other. History of current Briefly describe cause of wound if known. problem Assessment Prior to each dressing change, an assessment of the wound is recommended to note changes and ensure treatment is appropriate. Current pressure wound stage/depth Indicate pressure wound stage with a check mark in the appropriate box. For non-pressure wounds indicate depth with a check mark in the appropriate box. Wound Bed Color Indicate wound bed color with a check mark in the appropriate box. If wound bed is yellow or black, indicate the percentage of wound covered. Exudate: Amount: Indicate the amount of drainage following the abbreviations provided ie. Scant drainage where only the wound is moist = SC. Color: Indicate the color of the exudates following the abbreviations provided ie. Sero-Sanguineous (clear pink) = SS. Odor Following wound cleansing indicate yes (Y) or no (N) for presence of odor. Peri-Wound skin Indicate the condition of the skin around the wound using the numerical codes ie. 4=edema. If other is indicated, record observations in clinical notes. Wound Measurement Indicate the area of the wound in centimeters. Note length x width x depth. Tunneling Indicate tunneling with an arrow on the clock face. Undermining Indicate Undermining with shading on the clock face. Pain Rate pain using a 0 to 10 point scale zero being no pain and ten being the worst pain imaginable. If resident is unable to provide this information, indicate pain with a yes or no, describing the pain response in clinical notes ie. Facial grimacing when wound cleansed. Photo Indicate yes (Y) or no (N) if a photo has been taken with this assessment. o A photo should be taken as a baseline measurement for all new wounds at the initial assessment. o A photo should be taken whenever there is a change in wound status. o Include a disposable tape measure in the photo to provide a reference to the size of the wound. o Attach resident label, date, size, no flash comment, body part, arrow towards head/toes, initial. o Attach printed photos as appropriate. Wound Treatment Indicate: Protocol o Frequency of dressing change o Treatment protocol eg. Cleansing method, dressing product, peri-wound treatment, method of fixing dressing etc. o Goal of treatment ie. Maintain current status, heal wound. o Use Revised Wound Treatment Protocol to record changes in wound treatment. Dressing Change Provide date, time, and signature for each dressing change. Wound Assessment and Treatment Record Revised November 2014 Page 4 of 2