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Skin tear project

Skin tear project. SHERI SANDISON VASCULAR CLINICAL NURSE CONSULTANT. Project. Literature search Audit current practice Develop & implement guidelines Publish Re-audit Ongoing education program. Project team. Barb Hutchinson Deb Muir Beth McErlean Sheri Sandison Wendy Humphreys

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Skin tear project

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  1. Skin tear project SHERI SANDISON VASCULAR CLINICAL NURSE CONSULTANT

  2. Project • Literature search • Audit current practice • Develop & implement guidelines • Publish • Re-audit • Ongoing education program

  3. Project team • Barb Hutchinson • Deb Muir • Beth McErlean • Sheri Sandison • Wendy Humphreys • Wound Management Committee

  4. A skin tear is: …a traumatic wound occurring principally on the extremities of older adults, as a result of friction alone or shearing and friction forces which separate the epidermis from the dermis or which separate both the epidermis and the dermis from underlying structures. [Payne-Martin, 1993]

  5. Literature Search: • Payne-Martin Classification system: • facilitate clinical judgement • provide opportunity to evaluate the effectiveness of selected treatments, • provide consistency of documentation and communication • provide a mechanism for estimating the healing time and costs associated with care.

  6. Payne-Martin Classification Category 1

  7. Category 2 (A & B)

  8. Category 3

  9. Literature Search: • Limited acute setting prevalence data • No optimal treatment but treatment aims to: • Stop bleeding • Prevent infection • Recover skin integrity • Promote healing • Minimise pain /promote comfort • Varied healing rates & costs

  10. Audit • Number of skin tears • Classification • Location • Cause • Wound management practice • Documentation

  11. Results • 10.7% (3.8% orthopaedic to 27% palliative care) • Majority class 2A (<25% epidermal loss) • 25% from fall • 63% upper body; 36% lower body • Varying dressing choices: 24% no dressing • Scant documentation

  12. Guidelines • Preventative measure • Immediate action • Assessment / classification • Dressing choice • Discharge • Documentation

  13. Preventative Measures: • Protect the Skin: • Use emollients, low pH soaps and moisturisers • Protect lower limb • Ensure equipment with any sharp edges is padded • Apply adhesive tapes without tension and with caution • Remove tapes with caution – slowly peel away from anchored skin; consider use of adhesive removing wipes • Promote shoes that are well fitted and refer to Podiatry if required.

  14. Preventative Measures: • Move without Damage • Use palms of hands to move patient, avoid pulling the skin • Use “Slippery Sam” or lifting device • Promote clutter free environment • Provide good lighting (e.g. night lights) • Use care when bathing, dressing, transferring &transporting “at risk” patients

  15. Immediate Action: • Gently cleanse the skin tear site, removing any debris • Gently return skin back into position using moistened cotton buds • Debride non-viable tissue

  16. Dressing choice: • The Challenge is to consider: • Varied nursing skill level & knowledge • Properties of the dressing product (e.g. absorbency, ease of application & removal) • Product availability & cost • Discharge destination

  17. Product Guidelines: • No single product appropriate for all skin tears. • Match the dressing choice with the skin tear category • Promote healing • Reduce trauma • Manage exudate • Protect flap • Protect peri-wound

  18. Category 1 : • Steri-strip approximated skin in position without tension. • Cover with low adherent gauze dressing, & melolin, tubifast or crepe bandage. • Change secondary dressing (melolin) prn. • Complete dressing change on Day 3. • Leave steri-strips insitu until they curl & lift off

  19. Category 2: • Cover with hydrofibre dressing & thin Hydrocolloid • Change according to degree of exudate i.e. evidence of leakage or hydrocolloid bubbling. • Low exudate = thin hydrocolloid • Moderate / high exudate = Hydrofibre & thin hydrocolloid

  20. Category 3: • Cover with hydrofibre and thin Hydrocolloid • Change according to degree of exudate i.e. evidence of leakage or hydrocolloid bubbling. • Low exudate = thin hydrocolloid • Moderate / high exudate = Hydrofibre & thin hydrocolloid

  21. On Discharge: • Ensure patient education is provided re wound care and prevention strategies (brochure) • Ensure community nursing is arranged including ongoing management plan and dressing supplies

  22. Documentation: • Cause • Site • Classification • Dressing type • Progress • Note specific interventions on bedside folder front sheet • Commence wound management chart • Activate Excelcare wound management UOC • Complete AIMS incident report

  23. Implementation / education program • Poster • Wound management folder • Education • Ward in-service talks • Ward wound resource nurses promote • Wound management course • Graduate nurse study days • Ward orientation • Audit data analysis – action plans

  24. Re-evaluate / audit

  25. August 2005 Audit results • Location: upper and lower extremities • Dressing choices – improved compliance to guidelines. • Numbers too small for statistical significance. • Need ongoing education • 3 x year auditing

  26. Lessons learnt • A problem with aging population • Guidelines are valuable • Specific to your location • Ongoing education for prevention & management • Evaluation / audit

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