SKIN CARE
PROGRAM		 Skin Care Alert
For all patients with
Braden Scale score of 16
or less and patients
admitted with pressure
ulcer		 Stage I
Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration.  In individuals with darker skin, discoloration of the skin,warmth, edema, induration, or hardness may also be indicators.		 Stage II
Partial thickness skin loss involving epidermis, dermis or both.		 Stage III
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.  The ulcer presents clinically as a deep crater with or without undermining adjacent tissue.		 Stage IV
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon or joint capsule).

Note:   When eschar is present, an ulcer cannot be
accurately staged until the eschar is removed
High Risk for
impaired skin
integrity		 Outcomes  Patient skin integrity maintained
                    Patient will leave the hospital with no pressure ulcers
Alteration in skin
integrity		 Outcomes  Progress will be made in reversal of any existing pressure ulcers
A.  Pressure           relief 1.  Do not massage skin
    over bony
    prominences or
    reddened areas
2.  Static air or A?P
     overlay
3.  Heel and elbow pads
     to reduce friction
4.  Chair cushion		 Same

 

 

 

 Same

 

 

 

 Same

 

 

 

 Same

 

 

 
B.  Activity 1.  Reposition at least every 2 hours and document.
2.  Use pillows or other devices (not donuts) to lift heels off bed.
3.  Keep the head of the bed less than 30 degrees, and limit the amount of time the head of the bed is elevated (unless contraindicated).  Use pillow or foam wedges to keep legs apart when the
     patient lies on side.
4.  Do not let patient lie directly on trochanter.
5.  Do range of motion q 2 hrs. and prn.
6.  Utilize life sheet.
7.  Ambulate or exercise as able.
8.  Up in chair not more than 1 hr. at a time.
9.  Don't position pt.  On pressure ulcer.
C.  Nutrition 1.  Encourage fluids
     (240cc q 2 hr.)
     unless restricted
2.  Nutritional consult		 Same

 

 Same

 

 Same

 

 Same

 
D.  Perineal care 1.  Incontinent care q 2
     hr. and prn
2.  Assess diaper and
     absorbent pad use		 Same

 

 Same

 

 Same
3.  Assess for indwelling/external catheter

 

 Same as Stage III

 
E. Education Provide pamphlet Same Same Same Same
F.  Dressing
     treatment		   1.  Cleanse with mild soap or personal cleanser.
2.  Apply dressing if desired. Change q 5-7 days.
     a.   Thin foam
     b.   Thin hydrocolloid
3.  Document
4.  Fax copy of wound assessment to Quality  Management		 1.  Cleanse with Normal  Saline
2.  Dressings should be changed q 3-5 days
     a.   Hydrocolloid
     b.   Wound gel
     c.   Wound gel sheet
     d.   Calcium Alginate sheet or rope
     e.   Thin foam
3.  Document
4.  Fax copy of wound assessment to Quality
     Management		 1.  Cleanse with Normal Saline.
2.  Dressings
     a.   Hydrocolloid changed q 3-5 days and prn.
     b.   Calcium Alginate covered with clear                 transparent membrane changed q 1-3 days and prn.
     c.   Wound gel to cover wound surface.  If needed, fill cavity with guaze moistened with Normal  Saline or wound gel.  Cover with clear transparent membrane. Changed daily and prn.
3.  Document.
4.  Fax copy of wound assessment to Quality Management.		 1.  Cleanse with Normal Saline
2.  Dressings
     a.   Hydrocolloid changes q 3-5 days and prn.
     b.   Calcium Alginate covered with clear transparent   membrane changed q 1-3 days and prn.
     c.   Wound gel to cover wound surface.  If   needed, fill cavity with guaze  moistened with Normal Saline or          wound gel.  Cover with clear   transparent membrane dressing.  Change q 1-2 days and prn.
3.  Document.
4.  Fax copy of wound assessment to Quality
     Management
ACWCP - 1998                                           NOTE: FOR STAGE III OR IV WITH ESCHAR, DISCUSS NEED FOR SHARP DEBRIDEMENT WITH PHYSICIAN