Skin & Wound Care

Safe care requires thorough assessment, detailed documentation, early intervention and collaborative communication.

To view the Course Outline and take the exam online, click here.

For a printer-friendly version of the exam you can print out, complete and mail to ADVANCE, click here.

Learning Scope #427
1 contact hour
Expires April 1, 2015

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education offering is to provide the latest information to nurses about wound care. After reading this article, you will be able to:

1. Identify the four facets of safe skin care.

2. Describe the importance of open communication and education with patients and families.

3. Discuss the rationales for removing dressings upon admission and applying simple dressings prior to formal wound care orders.

The author has completed a disclosure form and reports no relationships relevant to the content of this article.

Each month, I meet with my hospital's newest group of nurses, some fresh out of school and some well-seasoned. As the certified wound nurse within the organization, I review specifics regarding hospital policy, protocol and formulary related to excellence in skin health.

For as long as I've been conducting orientation, I am continually amazed by both the fear and dislike of all things skin and wound related. Providing safe skin and wound care may seem like an overwhelming task, but it can be achieved with the practice of a thorough assessment and common sense interventions.

I have gained much insight during these introductory lectures and they will be shared with you, with the intent to deescalate fear and spur confidence.

Why is the skin aspect of an admission assessment so dreaded? Is it considered heavy, laborious and time-consuming work? Does technical terminology cloud critical thinking and make documentation confusing? What is it about the characteristics of a wound that elicits so much angst? Is it the sensory onslaught of sight and smell? Is it uncertainty about which dressings to apply? Or is it all of the above (and everything in between)?

The unique nature of an individual is most revealed in their outside appearance. Capturing those diverse and distinctive characteristics could create clinical indecision. Regardless of one's trepidation regarding skin and wounds, our patients come to us as a complete package and must be regarded in their entirety.

First, let it be said that you do have the education and know-how to act in the best interest of your patient's skin. With a bit of shared insight mixed with some suggestions and rationales, you will be confidently performing comprehensive skin and wound assessments upon admission (and at all times thereafter) as well as play an integral role as a member of the healthcare team by participating in excellent skin and wound care.

Initial Assessment

A thorough head-to-toe skin and wound assessment, detailed documentation, early skin health interventions and timely communication and collaboration with the healthcare team equates to safe and comprehensive nursing care.

A nurse's assessment findings are assembled like puzzle pieces to tell the story of the whole patient. The details of the integumentary assessment are no exception. Clinicians both realize and appreciate that skin is the largest organ of the body, responsible for providing multiple complex functions to protect the human within, yet the skin is often overlooked and neglected. And frankly, a cursory peek under the sheets is not a thorough means of assessment.

Benignly asking a patient if she has any skin concerns (in lieu of the actual physical examination) simply does not suffice. People, especially the elderly, tend to "put up" with skin conditions and may deny issues that would otherwise be of concern.1

Never before has capturing a patient's skin and wound status on admission been more important in this tumultuous era in healthcare. In simple terms, healthcare organizations are not reimbursed for what the Centers for Medicare and Medicaid Services (CMS) considers "never events." Full-thickness pressure ulcers, either missed on initial assessment or acquired during one's hospitalization, fall into this category.2 It is imperative to account for any and all pressure ulcers (and other breaks in skin integrity) upon admission.

A timely, systematic and thorough skin assessment is necessary upon admission - and at least daily thereafter - to effectively care for the entire patient.3 As a matter of fact, head-to-toe and every crack and crevice in between is fair game. Observation of the regular and customary skin color, turgor and temperature just scratches the surface, offering only a broad sweep of insight that will lead to a more detailed and telling inspection.

Before initiating an assessment, take the opportunity to educate patients (and their families) about the importance of skin health and the necessity of performing a comprehensive examination. Our patients and their families are our best partners in providing safe care. Taking a few moments to inform them about your role and their help in skin protection will increase awareness and safety.

Begin the skin assessment at the top and work your way down in a systematic approach. Check the back of the head, behind the ears, under arms, breasts, abdominal and groin folds, in the gluteal cleft and all the way to heels and toes. All skin must be accounted for. Pay close attention to bony prominences, vulnerable to unrelieved pressure. Ask about skin and wound history, including dermatologic conditions, risk for bruising, non-healing wounds and history of pressure ulcers.

Remove or reposition medical devices, including compression stockings, nasal cannulas or blood pressure cuffs to visualize skin hidden from obvious view. Medical devices can cause undue pressure and trap heat, resulting in skin breakdown.4 Also consider that more darkly pigmented skin may not readily reveal pressure-compromised areas. Sometimes visualization of one's skin alone is not enough, and the use of tactile assessment techniques is required to detect the more subtle skin changes associated with reduced circulation.5 Dryness, edema and/or induration should be noted as potential areas of compromise in darkly pigmented patients.6

Any compromise in skin integrity, including tears, abrasions, denudement (erosion), bruising, pressure, vascular or neuropathic ulceration, resurfaced scars and other breaks in skin integrity require further evaluation. Carefully note details of observed alterations as you proceed for later documentation.

A helpful tool is a body outline diagram. A simple front and back anatomical drawing serves as a visual to assist in tracking sites of skin compromise. Whether the tool is used to jot down notes or to eventually become part of the permanent medical record, a simple body outline helps to keep notations orderly during the assessment.

Meeting Challenges

Managing patients with the presence of a wound (including the assessment, documentation and care thereof) gets the most resistance and recoil from nurses. In fact, clinicians may challenge the necessity of removing a perfectly clean, dry and intact dressing during an admission assessment. Historically, it was enough to declare that a dressing was present and that it was "clean, dry and intact" when in fact removal of all dressings is imperative upon admission.

Gathering baseline data are necessary to ensure wounds are clean and healing, free of infection and are being treated with appropriate therapeutic interventions. In addition, a wound offers further insight into a patient's overall health status and history. During a wound assessment, ask the patient about details, including the etiology and chronicity, to gather a history which will help in later care planning.

It should be noted there may be circumstances when a dressing must be left in place if a patient's clinical condition would be compromised upon removal. An example of this might be a surgical dressing which might best be removed by the surgical staff. Be sure to follow your facility's policy regarding this. If the nurse has any uncertainty, she must seek further guidance and direction from the provider. Otherwise, what lies beneath must be included in a comprehensive skin evaluation.

The assessment of a wound should capture as much detail as possible. Wound characteristics are as individual as are the people to whom they belong. Your job is to gather information about all that you see. A thorough wound assessment includes the following descriptors: size, depth, edges, undermining (tissue destruction underlying intact skin along wound margins), tunneling, necrotic tissue type and amount, granulation and epithelialization tissue presence, exudate type and amount, and surrounding skin characteristics, including the presence of edema and/or induration.7

An invaluable tool to have during a wound assessment is a cotton-tipped applicator encased in a paper measuring guide for accurate wound measurement. Don't guess on wound size. Ensure you are measuring per your organization's protocol. A measuring protocol ensures uniformity and will equate to accurate wound tracking and will ultimately guide effective wound care.

Once the assessment is concluded, the nurse must redress the wound. Check with your particular organization before providing wound management. Many organizations have nursing protocols that allow for simple wound care interventions that can be initiated by the nurse while awaiting more detailed provider orders. The goal at this time is to protect the wound and do no harm.

The very characteristics of the wound will guide which basic dressings should be applied. A draining wound requires an absorptive dressing. A dry wound would benefit from a moist, non-adherent dressing. A simple and uncomplicated dressing formulary takes the fear and guesswork out of dressing a wound.

A supply of normal saline solution, sterile gauze and skin-friendly tape will suffice for most wound care during this interim time between assessment and active treatment orders. Redressing a wound at this early stage of the game does not have to be complicated or feared. Keep it safe and simple.

Thorough Documentation

It is time to translate your detailed assessment into clear and thorough documentation. For whoever is reading the information you're providing, he or she should obtain an unmistakable and comprehensive picture of the patient's current skin (and wound) condition.

Either electronically or on paper, organizations often utilize structured formats to help guide a nurse in capturing the key components of particular body system assessments, ensuring all details are uncovered. Refer back to any observances you noted during the assessment. Using a pocket guide of common skin and wound descriptors/definitions is extremely beneficial. The clarity of one's documentation is a testament to the thoroughness of the assessment performed.

Some organizations integrate wound photography into the medical record. It must be noted that if wound photography is part of your facility's protocol, it must not be a substitute for a complete and through written portrayal. A picture may be worth a thousand words, but a clinician's personal assessment completes the story.

Initiate Early Intervention

Once a full assessment and skin history has been completed, a predictive pressure ulcer risk assessment tool (such as the Braden Scale for Predicting Pressure Sore Risk) should be completed. Factors such as a patient's sensory perception, activity level, mobility, nutritional status, moisture and friction/shear are assessed, and the results give the clinician insight into a patient's risk for skin compromise and ultimately guide early intervention.8 Identified risks will help guide needed nursing interventions to help protect skin from further compromise.

For patients identified as being at risk for pressure ulcers or other compromises in skin integrity, nursing interventions are really quite simple and common sense. Routine turning and repositioning, off-loading pressure to heels from mattress surfaces, use of mild skin cleansers and moisturizers, and careful attention to incontinence management are examples of simple yet effective interventions.

Discuss identified risks with patients and families so they can partner in skin safety. Shore up support with assistive nursing personnel so preventive measures will be maintained.

Communication & Collaboration

Your job is not finished. Any alterations in skin integrity must be communicated to the provider. Don't assume the provider is already familiar with the patient's skin integrity. Your key assessment findings should be incorporated into the patient's overall plan of care. The provider will make determinations for further clinical referrals based on the details you provide.

Surgical, infectious disease and nutrition consults are commonly requested in the presence of chronic, infected, necrotic and/or non-healing wounds. In addition, if your organization employs a certified wound nurse, take advantage of that available expertise. The wound nurse will further assess compromised skin and chronic wounds and help in formulating an individualized care plan.

Don't hesitate to collaborate with the medical and surgical teams and offer your recommendations for further skin care based on your findings. Reluctance to advocate for what you know is considered safe and appropriate skin and wound care may result in pain and suffering, delayed healing and/or an increased length of stay.

Open communication among the nursing team also is imperative. It is suggested that during report skin be reviewed, just like other body systems. Include details of wound management and any particulars of dressings or treatments that are ordered. Team up with assistive nursing personnel to ensure skin is being appropriately cared for during routine care. General hygiene cares, including helping to keep patients dry and comfortable, may be delegated. Simple solutions, including mild cleansing and moisturizing, may be enough to ensure a patient's skin remains healthy during their stay.9 Encourage and empower assistive personnel to contact you should any concerns be noted during their patient interactions.

Providing Excellent Care

Safe care requires thorough assessment, detailed documentation, early intervention and collaborative communication. Protecting and maintaining skin integrity is critical. The nurse is the likely conduit between patients and providers, playing a key role in orchestrating safe and appropriate care. Providing effective skin and wound care, though what some deem uncertain and fretful work, is part of the entire nursing care process. Meeting those fears head on is the best way to gain confidence and ensure provision of excellent patient care.

References
1. Cowdell F. Promoting skin health in older people. Nurs Older People. 2010;22(10):21-26.
2. Agency for Healthcare Research and Quality. Patient safety primers - never events. http://www.psnet.ahrq.gov/primer.aspx?primerID=3
3. National Pressure Ulcer Advisory Panel. Pressure ulcer prevention points. http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-prevention-points
4. Black J, Cuddigan J, Walko M, et al. Medical device related pressure ulcers in hospitalized patients. Int Wound J. 2010;7(5):358-335.
5. Lyder C. Closing the skin assessment disparity gap between patients with lightly and darkly pigmented skin. J Wound Ostomy Continence Nurs. 2009;36(3):285.
6. Clark M. Skin assessment in dark pigmented skin: a challenge in pressure ulcer prevention. Nurs Times. 2010;106(30):16-17.
7. Harris C, Bates-Jensen B, Parslow N, et al. Bates-jensen wound assessment tool: pictorial guide validation project. J Wound Ostomy Continence Nurs. 2010;37(3):253-259.
8. Gadd M. Preventing hospital-acquired pressure ulcers: improving quality of outcomes by placing emphasis on the braden subscale scores. J Wound Ostomy Continence Nurs. 2012;39(3):292-294.
9. Ananthapadmanabhan K, Subramanyan K, Nole G. A global perspective on caring for health stratum corneum by mitigating the effects of daily cleansing: report from an expert dermatology symposium. Br J Dermatol. 2013;168 Suppl 1:1-9.

Lisa K. Owens is program manager of the wound, ostomy and continence department at Mercy Medical Center, Baltimore.




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