POLICY:

1. To promote healthy intact skin.
2. To promote tissue healing.
3. To educate patient and/or significant others about prevention and/or treatment.
4. Follow established treatment program.
5. 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 for at risk patients.
   1. Elderly.
   2. Parkinson’s patients.
   3. Immunocompromised.
   4. History of steroid use.
   5. Underlying dermatologic condition.
   6. Highly edematous.
   7. Poor turgor.
   8. Long history of smoking.
   9. Confused.
   10. Fall prone.
2. Assess for contributing factors, such as equipment, fall, self-mutilation.
3. Assess skin trauma.
   1. Location.
   2. Size.
   3. Wound edges.
   4. Bleeding.
   5. Wound depth.
   6. Large or deep skin tear/laceration needing sutures.
   7. Pain.
   8. Erythema.
   9. Edema.
   10. Discharge/drainage.
   11. Eschar.
4. Assess educational needs.

B. PLAN:

1. Reduce or eliminate contributing factors.
2. Prevent skin trauma.
3. Use appropriate treatment to promote healing.
4. Provide education.

C. INTERVENTION:

1. PREVENTION:
   1. Pad equipment/furniture as needed.
   2. Keep nails short and/or glove if necessary.
   3. Apply tape without tension.
   4. Use porous type to allow moisture to evaporate.
   5. To remove tape, slowly peel tape away from anchored skin.
   6. Secure extremity dressings with roll gauze or tubular stockinette.
   7. Use skin sealants or solid - wafer skin barriers under adhesives.
   8. Secure dressings with Montgomery straps unless in a pressure area.
   9. Encourage to wear long sleeves and/or socks/stockings to protect extremities.
2. TREATMENT:
   1. Use aseptic technique.
   2. Cleanse area with normal saline or noncytoxic wound cleanser. DO NOT USE PEROXIDE.
   3. Skin present.
      1. Slide edges together to approximate.
      2. Steristrip edges in place.
      3. Cover with:
         1. Transparent film dressing if the skin has good turgor and there is little to no edema. Change every 3-7 days as long as integrity is maintained and the fluid which collects underneath remains clear.
         2. Nonadherent dressing and wrap if the skin has poor turgor and/or there is edema present. Apply topical antimicrobial ointment if desired. Change outer dressing daily.
   4. Skin absent.
      1. Trim any remnants of skin that are avascular.
      2. Cover with:
         1. Hydrocolloid if the skin has good turgor and there is little edema. Change every 3-7 days.
         2. Topical antimicrobial ointment/Silvadine and nonadherent dressing, then wrap if the skin has poor turgor, edema or high amount of drainage is present. Change daily and prn.
         3. Hyrdrogel wafer/sheet if wound is painful. Secure with gauze wrap. Change every one to two days and prn.
         4. Exudry and Silvadine may be used if there is a high amount of drainage. Change daily and prn.
   5. If large deep skin tear/laceration needing sutures, notify physician/emergency room.
   6. Notify health care provider of signs and symptoms of infection.
   7. Discontinue dressing when healed.
3. EDUCATION:
   1. Minimize trauma by wearing garments which protects the skin especially the extremities.
   2. Types of dressings and techniques for dressing application.
   3. When to report skin tear to a health professional.
   4. Signs and symptoms of infection.
   5. Expected wound appearance during the healing process.

D. EVALUATION

1. Monitor area of trauma daily.
2. Document on appropriate facility form.

ACWCP - 1998