POLICY:

A. To attain/maintain intact skin.
B. To participate in developing goals for the management program.
C. To discuss methods of prevention and individual management program.
D. To demonstrate individual management program.
E. To remain free of preventable complications.
F. Evaluate in two weeks for its effectiveness, if not improved, change course of treatment.
G. RN or designated skin care provider may determine the need for and implement appropriate skin care treatment.

RN, LPN - treatment
RN, LPN, CNA - preventive aspects

A. ASSESSMENT
        1. Assess extremities for redness, calluses, corns, and wounds.
        2. Assess peripheral pulses, capillary refill, and pain.
        3. Assess skin for hair, color, temperature, sensation, wound depth and margins, exudate,               edema, granulation, infection, necrosis, eschar, and gangrene.
        4. Assess smoking history, caffeine intake, and blood sugars.
        5. Assess nutritional status.
        6. Assess mobility, especially gait, and activity.
        7. Assess need for consultants - dietitian, enterostomel therapy nurse, occupational               therapist, pharmacist, physical therapist, podiatrist.
        8. Assess wound by using wound assessment form weekly and change in condition.
        9. Assess educational needs.
        10.Assess ability to perform treatment.

1. Maximize blood flow.
2. Prevent recurrent ulcer formation.
3. Prevent trauma.
4. Reduce infection risk.
5. Provide skin care to legs and feet.
6. Promote optimal nutritional and fluid intake.

C. INTERVENTIONS:

1. Eliminate vasoconstrictive agents (caffeine, tobacco).
2. Avoid exposure to cold.
3. Avoid constrictive garments.
4. Maintain leg position appropriate to ulcer etiology.
5. Ambulate to tolerance.
6. Correctly apply vascular support devices.
7. Monitor for circulatory impairment.
8. Control weight.
9. Avoid thermal trauma:
   1. Temperature extremes
   2. Heating pads
   3. Hot water bottles
   4. Heat lamps
   5. Hot/cold solutions and soaks
   6. Sunburn
   7. Frostbite
   8. Ice packs
10. Avoid mechanical trauma:
    1. Constrictive shoes
    2. Walking barefoot or with open sandals
    3. Cutting and trimming corns and calluses
    4. Adhesive tapes
    5. Improper shaving
    6. Vigorous massage
11. Avoid chemical trauma:
    1. Over-the-counter preparations for corn and calluses removal
    2. Drying and irritating agents
12. . Do not soak feet.
13. . Carefully dry between toes.
14. . Do not apply lubricant between toes.
15. . Report any cuts, burns, or breaks in skin to health care provider promptly.
16. . Do not use harsh disinfectants (iodine, povidine iodine, peroxide).
17. . Keep feet and legs clean and well lubricated.
18. . Daily feet inspection.
19. . Non-constricting white natural fiber socks to absorb moisture.
20. . Avoid irritating dyes.
21. . Optional use of powders to absorb moisture and reduce friction.
22. . Report symptoms of change in color, temperature, sensation, pain, or presence of       drainage and odor to health care provider.
23. . Topical therapy
    1. In presence of gangrene or necrotic tissue, collaborate with appropriate health care provider.
    2. When debridement is needed.
       1. Use enzymatic debriding agent.
       2. Autolytic debridement using moisture vapor permeable transparent dressing.
       3. Autolytic debridement using hydrogels.
       4. Autolytic debridement using hydrocolloids dressing.
       5. Mechanical debridement using wet-to-dry dressing.
       6. Mechanical debridement using hydrotherapy.
       7. Surgical consultation.
    3. For non-necrotic ulcers.
       1. GENTLE wound cleansing at each dressing change.
       2. Transparent adhesive dressings.
       3. Hydrocolloid dressing.
       4. Hydrogel dressing.
       5. Moist gauze dressing.
       6. Medicated creams and ointments.
       7. Alginate.
       8. Foam dressing.
    4. Protective skin sealant under adherent dressings or tapes.
    5. Gauze dressings secured in non-adhesive manner.
    6. Adhesive solvents when indicated to remove excessive residue.
    7. Evaluate progress in wound healing on a regular basis and request medical/surgical consultations when needed.
    8. Recommend or implement therapy to provide venous compression.
       1. Zinc oxide impregnated support wrap.
       2. Pressure gradient support stocking and wraps.
       3. Sequential, intermittent compression device.
24. . Education
    1. Provide audiovisual aids to enhance verbal discussion.
    2. Observe patient and/or significant other perform treatment.
    3. Blood glucose control.
    4. Nutritional status.
    5. Compliance of patient and/or significant other.

1. Monitor skin surfaces daily.
2. Monitor based sugars as ordered.
3. Monitor nutritional intake daily.
4. Monitor circulation daily.
5. Document on appropriate facility form.

ACWCP - 1998