CLINICAL PROTOCOL FOR WOUND MANAGEMENT AND WOUND MANAGEMENT STANDARDS
Skin Integrity And Wound Management...WOUND ASSESSMENT And Wound Management Admission •Each...
Transcript of Skin Integrity And Wound Management...WOUND ASSESSMENT And Wound Management Admission •Each...
Skin Integrity And Wound Management
Introduction
• The wounds we find in today’s Long Term Care facilities are varied and sometimes difficult to close. In addition to the need for the use of evidenced-based best practice guidelines, we as professionals need to be up to date on the accepted techniques for treatment..
• Additionally, we ALWAYS have to follow the guidelines for documentation as found in your Corporate Policy and Procedures.
Admission
Follow your corporate’s policy
regarding the completion of the
admission paperwork
Include a bradenscale assessment
Document all findings in the
appropriate manner
RESIDENT’S RIGHTSAnd Wound Management
Social Security Act Of 1987
• This law requires nursing homes to promote and protect the rights of each resident.
• Strong emphasis is placed on individual dignity and self-determination.
Actions
• Knock on the resident’s door prior to entering the room
• Address the resident by name and introduce yourself
• Assure that the timing of your visit to the resident’s room is convenient for the resident and any visitors present
• Provide for privacy
• Explain the purpose of your visit to the room, asking his/her permission to proceed with the procedure, etc.
What to do next
• Gather the needed supplies
• Review the resident’s order fior treatment
• Wash hands….Always
• Cleanse the bedside table/tray with an antibacterial cleaning wipe and cover with a non-permeable barrier drape
• Place the supplies onto the drape
Remember
Only one wound should be treated at a time. Treat every wound separately.
Next…
• Put on gloves
• Remove the soiled dressing and discard in a plastic bag
• Remove gloves and wash hands
• Open packages of wound supplies on the non-permeable drape/tray
• Replace gloves
• Complete the dressing change
• Change gloves and repeat the process – using a new set up for each additional wound
Remember
• Provide for the resident’s comfort at all times!
• If the resident complains of discomfort, stop the treatment, cover the wound with a cover dressing and follow steps to ensure resident comfort
Wrap up…
• Discard contaminated supplies per infection control policy
• Document procedure on the treatment record
WOUND ASSESSMENTAnd Wound Management
Admission
• Each resident that is admitted to the facility, and re-admitted after a hospital stay, must have a full skin assessment completed within 8 hours of arrival to the facility
Assessment guidelines
• Every nurse should be able to measure and document the presence of skin breakdown
• This includes bruises, rashes and scars, as well as open wounds
Process
• Using the approved assessment tools, determine a resident’s risk level for skin breakdown
• Visualize the skin!! Look in every crack and crevice!
• Document the location of any skin breakdown or scarring
• Determine the etiology of the wound (use the history and physical)
Process
• Document: wound size (in cm), color of tissue (pink, red, yellow ,gray, brown, black), location (use anatomical location terms), stage (if pressure) or thickness (full or partial), and odor
• Document: condition of the periwound (warmth, redness, pain, edema, fluctuance, weeping)
• Document the color, odor and amount of drainage
Process
• Identify s/s of contaminated wounds
• Identify s/s of infected wounds
• Identify s/s of a healing wound
Process
• Staging
• Necrotic tissue
• Full thickness
• Partial thickness
• Arterial
• Venous
• Diabetic
• Burns
• Miscellaneous
Process
• All documentation is to follow your policy and procedure
• Weekly documentation is mandated
Wound Measurement
• Measure in centimeters only
• Use the “clock” method to determine length and width
• Measure the longest point from 12:00 – 6:00, or head to toe to determine length
• Measure the widest point from 3:00-9:00, or side to side to determine width
Wound Measurement (cont’d)
• To determine depth, the base of the wound must be visible
• Use a cotton swab to measure from the base of the wound to the level of the skin surrounding the wound
• Undermining – “skin shelf”
• Tunneling – narrow space extending away from the wound
Questions?And wound management
Skin Integrity and Wound Management_Daybreak_2016_12_22