Wound Management Policy
July 2012
Version 2
Table of Contents.
1.0 Policy Statement: 4
2.0 Purpose: 4
3.0 Objectives: 4
4.0 Scope: 4
5.0 Definitions: 4
6.0 Responsibilities. 5
7.0 Assessment and Care Planning Protocol. 6
7.1 Pre Admission Assessment: 6
7.2 Skin Assessment And General Preventative Skin Care. 6
7.3 Skin Care. 7
7.4 Hygiene and Total Emollient Therapy 8
8.0 Prevention of Pressure Ulcers. 9
8.2 Risk Factors. 9
8.3 Care Planning to Prevent Pressure Ulcers. 9
8.4 Use of Pressure Relieving Equipment. 10
8.5 Care and Maintenance of Mattresses. 10
8.6 Support Surfaces to Prevent Heel Pressure Ulcers. 11
8.7 Repositioning Technique. 11
8.8 Repositioning for the Seated Resident. 11
8.9 Use Of Support Surfaces To Prevent Pressure Ulcers While Seated. 12
8.10 The Use Of Other Support Surfaces In Pressure Ulcer Prevention 12
8.11 Prevention of Pressure Ulcers Protocol. 13
8.12 Pressure Relieving Equipment Protocol. 14
8.13 Pressure Ulcer ClassificationTool. 15
9.0 Prevention and Management of Skin tears. 16
9.1 Skin Tear Definition. 16
9.2 Risk Factor for Skin Tears. 16
9.3 Care Planning for Skin tears. 16
9.4 Strategies for Prevention of Skin Tears. 16
9.5 Skin tears Classification System. 17
10.0 Guidelines for Prevention and Management of Skin Tears. 18
11.0 Wound Management. 19
11.1 Assessment of Wounds. 19
11.2 Assessing exudate. 19
11.3 General Care Planning for Wound Management. 20
11.4 Care Planning for Residents with Pressure Ulcers. 20
11.5 Infected Wounds. 21
11.6 Wound Swabbing. 21
11.7 Infection Control and Wound Dressing. 21
12.0 Use of Dressings 24
13.0 General Wound Dressing Guide 28
14.0 Wound Bed Preparation for Chronic Wounds. 30
14.1 Vacuum Assisted Closure (VAC) Therapy. 31
15.0 Management of Leg Ulcers. 32
15.2 Assessment of Leg Ulcers. 32
15.3 Five Key Areas of Leg Ulcer Assessment 32
15.4 Differentiating between Venous and Arterial Leg Ulcers. 33
15.5 Mixed venous / arterial ulcers 33
15.6 Aims of Leg Ulcer Management. 33
15.7 Management of the resident with a Venous Leg Ulcer. 34
15.8 General Skin Care for Residents with Venous Leg Ulcers 34
15.9 Cleansing Venous Leg Ulcers 34
15.10 Management of Arterial leg Ulcers. 35
16.0 Prevention and Management of Diabetic Foot Ulceration. 36
16.1 Assessment for Risk of Diabetic Foot Ulceration. 36
16.2 Management of A Diabetic Foot Ulcer. 37
17.0 References. 38
Document Title and Code: / Wound Management Policy / NMA-WM.Version: / 2
Author: / Prepared by Ms. Eithne Ni Dhomhnaill and Ms. Andrea O’Reilly, Nursing Matters & Associates.
Adapted for local use by:
Issue Date: / July 2012
Review date: / July 2014
Authorised by:
1.0 Policy Statement:
It is the policy of the Centre that assessment and care planning for skin care; prevention of pressure ulcers and management of wounds will be underpinned by an evidence based approach based on person centred assessment and care planning.
2.0 Purpose:
The purpose of this policy is to promote best practice in skin care and wound management for individual residents in the Centre.
3.0 Objectives:
3.1 To ensure that residents at risk of impaired skin integrity and pressure ulcers are identified and a plan of care developed to meet his /her needs, known wishes and preferences.
3.2 To provide guidance on skin care and wound management for all staff involved in providing direct care to residents.
3.3 To outline procedures and practices that must be followed for assessment and care planning related to skin care and wound management.
4.0 Scope:
This policy applies to all nursing and healthcare staff who are involved in providing direct care to residents. This policy applies to those wounds commonly seen in a residential care setting for older people such as, pressure ulcers; leg ulcers and diabetic foot ulcers. It does not apply to surgical or traumatic wounds which are usually seen in acute settings.
5.0 Definitions:
5.1 Wound: A wound is defined as a disruption of tissue integrity that is typically associated with a loss of substance. (Sedlarik 2003)
5.2 A chronic wound: ‘ is one in which the orderly sequence of repair is disrupted at one or several points of the inflammatory, proliferative, re-epithelization, and remodelling stages’ (Sibbald et al, 2000).
5.3 Pressure Ulcer: refers to ‘a break in the continuity of the skin caused by pressure, friction and shear. This type of damage can also be known as pressure sores, decubiti or decubitus ulcers’ (NICE, 2001).
5.4 A leg ulcer is defined as a loss of skin below the knee on the leg or foot, which takes more than 6 weeks to heal” (Dale 1983, cited in HSE, 2007)
6.0 Responsibilities.
Actions. / Responsible Person (s)A record of all staff that have read and signed this policy document will be maintained. / Person in Charge / Director of Nursing
Nurses and healthcare staff will be provided with an explanation of the wound management policy as part of an induction programme. / Person in Charge / Director of Nursing
All nursing and care staff will attend updates on wound management during induction and where there is a change in practice in this area. / Person in Charge / Director of Nursing
Nurses will maintain their competence in wound management and communicate any knowledge deficits / education needs to the Person in Charge / Director of Nursing / Line Manager. / All registered nurses.
Nurses and healthcare staff will sign the policy acknowledgement forms having satisfied themselves that they understand the contents of this policy document. / All nursing and healthcare staff.
Each resident should have an initial screening for the presence or risk of pressure ulcers as part of their admission assessment process and as part of their three monthly reassessment or more frequently if there is a significant change to their condition. / Admitting/designated nurse.
Any resident admitted with or developing a wound while in the Centre will have an assessment and care plan developed and documented in accordance with this policy. / Admitting/designated nurse.
Any pressure ulcer of grade 2 or more will be reported and documented as a clinical incident. / Senior nurse on duty when pressure ulcer identified.
Each resident with a risk for or presence of a pressure ulcer will have a care plan as per this policy developed in accordance with his/her needs and wishes. / Designated nurse in collaboration with the resident’s GP and other healthcare professionals involved in the residents care
Care plans will be developed in collaboration with the resident and /or representative and other healthcare professionals involved in the care of the resident. / Designated nurse in collaboration with other nurses on duty as well as other healthcare professionals involved in the resident’s care.
A full assessment of the resident’s needs and wishes will be carried out prior to the use of any equipment, aids or treatments to prevent and / or manage pressure ulcers. / Designated nurse
The use of any equipment / treatment to prevent or manage pressure ulcers will be in accordance with the requirements for informed consent. / Designated nurse
The resident will be monitored for the effectiveness or otherwise of treatments / interventions being used to prevent and / or manage pressure ulcer(s). / Nursing staff on duty.
Residents requiring specialist referrals for the prevention and/or management of a pressure ulcer will be referred as appropriate. / All registered nurses.
7.0 Assessment and Care Planning Protocol.
7.1 Pre Admission Assessment:
7.1.1 As part of the pre-admission assessment process every prospective resident will be screened for:
· The presence of any wounds.
· The presence of any skin conditions.
· Pressure ulcer risks.
7.1.2 This information will be obtained from the referring hospital/healthcare facility; the resident and / or the resident’s representative.
7.1.3 As part of the general risk assessment on admission, each resident will have a skin assessment and assessment of vulnerability to development of pressure ulcers using both the Centre’s Admission Assessment form and the Waterlow/Braden risk assessment.
7.1.4 Immobile residents will have a Waterlow/Braden risk assessment within 2 hours of admission and on the first day of admission for mobile residents.
7.1.5 Risk assessment should also include clinical judgement.
7.2 Skin Assessment And General Preventative Skin Care.
7.2.1 Assessment of the resident’s skin should be conducted as part of the resident’s admission assessment on the day of admission or within two hours for immobile residents or those with known risk factors for skin breakdown based on the pre-admission assessment and / or referral letters.
7.2.2 The resident’s consent as far as he / she is able should be obtained prior to carrying out a skin assessment. An explanation of how and why a skin assessment is being conducted should be given to the resident prior to commencing any skin assessment.
7.2.3 All areas of the resident’s skin should be examined so as to identify any skin lesions and to look for variations in skin quality in different areas of the body.
7.2.4 When conducting skin assessments, nurses should pay particular attention to sites where skin breakdown occurs most commonly, particularly pressure areas and skin flexures. Early assessment should include examination of bony prominences (sacrum, heels, hips, ankles, elbows) to identify early signs of pressure damage.
7.2.5 Where a resident has a dressing, this will be removed so as to complete a wound assessment on the resident.
7.2.6 Assisting residents with bathing provides a good opportunity to examine the skin completely.
7.2.7 General skin inspection and assessment must include the following:
· Colour – the nurse should observe for variation in colour around the body; also for jaundice (in the skin as well as in the sclera of the eyes), bruising, pallor and inflammation.
· Observation for any specific breaks, sores, ulcers or lesions. Measurements and photographs should be used where possible with the resident’s consent.
· Checking for texture and moisture, such as coarse and / or dry skin.
· Checking for skin turgor by pinching the skin on the forearm or chest. (Decreased turgidity will result in the skin 'tenting', or staying in position when pinched). Decreased turgidity may be due to normal changes in ageing skin but may also indicate the presence of dehydration or malnutrition.
· Checking the temperature of the skin using the back of the hand to identify any localised heat.
· Blanching response.
· Oedema.
· Induration (hardness) of an area of skin.
· Redness of the skin.
· The presence of discomfort or pain that may indicate pressure damage.
7.2.8 A care plan to address the resident’s skin care needs will be developed for residents who have any risk factors for skin breakdown,
7.2.9 The care plan must include:
· The identification of any risk factors for deterioration in skin integrity / skin breakdown. These can be obtained from the skin condition assessment domain and the Waterlow / Braden score.
· Interventions to address risk factors – some of these may be included under other domains such as when the resident is incontinent or has poor nutritional status.
· Any skin care needs related to the resident’s inability to care for their own personal hygiene.
· Skin care needs related to any existing skin conditions.
· Skin care needs related to incontinence.
· When and how often the resident’s skin needs to be inspected.
7.3 Skin Care.
7.3.1 The overall aims of skin care should be to:
· Prevent skin breakdown through promoting effective skin barrier function.
· Promote comfort for the older person.
· Encourage self-management wherever possible.
7.3.2 Skin condition and all interventions identified to care for the resident’s skin should be documented in the resident’s care plan and any changes should be recorded and acted upon as soon as they are observed.
7.3.3 Excess moisture due to incontinence, perspiration, or wound drainage must be identified and actions documented to eliminate this where possible. When moisture cannot be controlled, interventions that can assist in preventing skin damage should be used.
7.3.4 Consideration to the use of barrier creams should be given where residents are incontinent.
7.3.5 Skin injury due to friction and shear forces should be minimised through correct positioning, transferring and repositioning techniques.
7.3.6 Excessive rubbing over bony prominences must be avoided as this may cause additional damage to skin at risk of developing pressure damage.
7.3.7 Following assessment nutritionally compromised individuals should have a plan of appropriate support and/or supplementation that meets individual needs and is consistent with overall goals of therapy. Nutritionally compromised residents must be referred to the dietician in accordance with the Centre’s Nutrition and Hydration Policy.
7.3.8 Maintaining activity level, mobility, and range of movement is an important goal of care for residents in accordance with their ability and condition.
7.3.9 Soap should be avoided where possible, as it tends to dry the skin further. If soap is to be used, it should ideally be unperfumed and rich in moisturisers.
7.3.10 A soap substitute, such as aqueous cream is preferable to soap as it can be applied to the body and rinsed off with water or used on a sponge or flannel. Although this does cleanse adequately, soap can be used if required to wash flexures and groin or particularly dirty areas.
7.3.11 Washing water should not be too hot as the heat tends to dry the skin further, but it should be warm enough to be comfortable
7.3.12 A no-rinse cleanser, such as Clinisan can be applied during daily care for at least 14 days to reduce the risk of pressure ulcer formation.
7.3.13 Emollient soaps are more effective in prevention of skin tears than non emollient
7.3.14 Zinc cream or Sudocrem, if used for at least 14 days can reduce skin redness caused by incontinence in older adult residents in long term care.
7.4 Hygiene and Total Emollient Therapy (Penzer and Finch 2001 in HSE, 2007).
Over washing can be detrimental to the maintenance of healthy skin. Hygiene and total emollient therapy are at the centre of any strategy for promoting good skin health. These strategies improve skin barrier function and comfort and can promote a sense of well being. Emollient therapy is particularly beneficial for older people. Their skin produces less of the natural oils to protect the outer layer of skin, thus preventing moisture loss and flexibility. Applying emollients helps to mimic the actions of these natural products. Decreasing dryness will also help to reduce itching.