SKIN CAREWOUND CAREOSTOMY CARE :SKIN CAREWOUND CAREOSTOMY CARE Wound, Ostomy and Continence Nurses Your clinical resource for patient care. Contact by Phone: 2-3233 Simon Pager Pamela Srinivas #11610 Bobbie Rinard #11335


SKIN CARE :SKIN CARE Objectives Identify patients at risk for skin breakdown. Identify prevention Plan of Care Identify goals of treatment Identify products for prevention and treatment


Causes of skin breakdown :Causes of skin breakdown Pressure Increased Risk when Braden Score 17 or less Moisture Clean, Protect , Contain Friction Handle With Care Shear Caution with Head of Bed Elevation


Causes of skin breakdown:PRESSURE Assessment :Causes of skin breakdown:PRESSURE Assessment Braden Score 17 or less See Interdisciplinary Plan of Care Interventions Score of 1 or 2 in any Braden Scale category See Specialty Bed Decision Tree on Intranet Complex problems and questions Contact Wound Care Nurses Phone 2-3233 Simon Pager


Specialty Bed Decision Tree :Specialty Bed Decision Tree It is YOUR responsibility to evaluate patients for a specialty bed. Go to Intranet. Select Staff Toolbox. Choose Specialty Bed Decision Tree. Follow directions. See bed rental instructions. Call Lana Beckley, Clinical Equipment Specialist with questions. Phone 2-6148 or Simon Pager #11835. 1st Step Select KinAir MedSurg


Causes of skin breakdown:PRESSURE Interventions :Causes of skin breakdown:PRESSURE Interventions Reduce Pressure - 30° lateral position with wedges or pillows. Patients on Specialty Beds must also be turned. Keep heels off bed with positioning devices, pillows or foam boots.


Causes of skin breakdown: PRESSURE Interventions :Causes of skin breakdown: PRESSURE Interventions Reduce Shear and Friction – maintain head of bed at lowest position possible.


Causes of skin breakdown: MOISTURE :Causes of skin breakdown: MOISTURE Skin with too little moisture is 2.5 times more likely to ulcerate than healthy skin Skin with too much moisture is 5.0 times more likely to ulcerate than healthy skin Apply Moisturizer Apply Moisture Barrier


INCONTINENCE CARE:Goals of Moisture Protection :INCONTINENCE CARE:Goals of Moisture Protection Cleanse Protect Contain


INCONTINENCE CAREGoals of Moisture Protection: Cleanse :INCONTINENCE CAREGoals of Moisture Protection: Cleanse Comfort Baths microwaveable wash cloths for bathing. NOT APPROPRIATE for incontinence care.


INCONTINENCE CARE: Cleanse :INCONTINENCE CARE: Cleanse CarraFoam Skin & Perineal Cleanser pH balanced, better than soap, no rinse formula. Use with disposable paper wash cloths or baby wipes.


INCONTINENCE CARE: Protect Intact Skin :INCONTINENCE CARE: Protect Intact Skin Baza Protect Skin Protectant Cream. Ingredients: Zinc oxide and Dimethicone Apply a thick layer to perineal area


INCONTINENCE CARE: Protect raw, weeping, damaged skin :INCONTINENCE CARE: Protect raw, weeping, damaged skin Critic Aid Skin Paste Apply a thick layer. No need to remove all paste with next cleaning. Once Critic Aid Skin Paste is applied, stool and urine do not contact raw skin. Gently clean with CarraFoam and reapply Critic Aid Skin Paste. Adheres to denuded skin.


INCONTINENCE CARE:Other Products :INCONTINENCE CARE:Other Products Ilex Skin Protectant Paste Apply to fissures or cracks in skin: between buttocks, under breasts, in groin and abdominal skin folds. No Sting Barrier Film Protects skin from tape damage and moisture.


INCONTINENCE CARE:Treat yeast and fungus :INCONTINENCE CARE:Treat yeast and fungus Baza Antifungal with 2% miconazole in a moisture barrier. Micro-guard Antifungal Powder with 2% miconazole.


INCONTINENCE CARE:Goals of Moisture Protection - Contain :INCONTINENCE CARE:Goals of Moisture Protection - Contain Diapers should rarely be used. Place absorbent disposable pads under patient (not blue plastic “chux”). Place Dri-flow Pads next to patient’s skin – these have no plastic and allow air flow. Dri-flow Pads must be used with specialty beds to allow therapeutic air flow.


INCONTINENCE CARE:Goals of Moisture Protection - Contain :INCONTINENCE CARE:Goals of Moisture Protection - Contain Condom Catheters Fecal Incontinence collector Must be applied before skin damage occurs. Call Wound Care Nurses – we can help!


INCONTINENCE CARE:Goals of Moisture Protection - Contain :INCONTINENCE CARE:Goals of Moisture Protection - Contain Fecal Management System - tube inserted in rectum to contain liquid stool. Requires a MD order. Check for contraindications. Do not use “rectal tube” or “rectal Foley”.


Post Test – TRUE or FALSE :Post Test – TRUE or FALSE Patients with Braden Score of 17 or less are at risk for Pressure Damage. Interventions for Pressure Prevention are listed on the Interdisciplinary Plan of Care.


Post Test – TRUE or FALSE :Post Test – TRUE or FALSE Goals of Moisture Protection are: Cleanse Protect Contain


Post Test – TRUE or FALSE :Post Test – TRUE or FALSE It is a nursing responsibility to evaluate patients for Specialty Beds.


Post Test – TRUE or FALSE :Post Test – TRUE or FALSE Wound, Ostomy and Continence Nurses are your clinical resource. No MD order needed to call with questions about skin, wound and ostomy care.