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Goal: To keep every resident’s skin clean, healthy, and free from sores.
 

Your Job in Skin Care
 

1. Check the Skin

• Observe skin daily

• Tell the nurse right away if you see redness, open spots, rashes, or any other skin changes

• Keep skin clean and dry. Change wet briefs or sheets right away.

• Use barrier creams per Care Card.
   

2. Turn and Move Residents

• Reposition per Care Card and as needed

• Keep heels off the bed when possible and as tolerated
   

3. Help With Wounds

• Do not remove dressings unless the nurse tells you to.

• Report if a dressing is wet, soiled, loose, or coming off.

• Watch for signs of infection: smell, drainage, redness, swelling, or pain. Tell the nurse right away.
   

Why It Matters

Your good care helps stop skin sores and keeps residents comfortable and healthy.

 

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Nursing Policy: Monroe Community Hospital

Title: SKIN CARE PROGRAM

Number: XIII-04
 

POLICY

 

Monroe Community Hospital is dedicated to utilizing best practices in wound care. Patients at high risk for impaired skin integrity will be identified using the Braden scale and prophylactic interventions will be implemented to mitigate the risk factors identified. Advanced wound healing strategies will be used to facilitate closure of existing wounds as quickly as possible in accordance with best practices.

Prevention

 

Identifying patients at risk

1. Braden assessments are completed by MDS nurses upon admission, quarterly and with a significant change of condition.

2. All completed Braden assessments will flow to the wound nurse’s EMR dashboard for review.

3. All residents with a history of pressure injuries within the past 12 months should be considered to be in the “high risk” category for prophylactic interventions.

4. The wound nurse will review all Braden assessments and initiate interventions to mitigate risk.

5. A member of the wound care team will screen all new admissions and readmissions for changes in skin integrity.

 

PPX interventions

 

Skin Checks

1. Skin checks will be performed once weekly prioritizing bony prominences.

2. If a new open area is identified the staff nurse should be notified.

3. The staff nurse should complete an electronic incident report in the EMR as soon as possible.

4. The new electronic incident report will flow to the wound care nurse’s dashboard.

5. The wound nurse will assess the site, generate a wound team consult and recommend an appropriate course of treatment.

Treatment (recommendations generated by the Internal Wound Team)

 

• MCH will follow all manufacturers’ guidelines and recommendations for use of their products at all times.

• The Wound Care RN should be consulted on all wound care treatment decisions unless following a current treatment protocol (see below).

• All wounds will be offloaded and advanced wound therapies will be utilized to promote wound healing in accordance with best practices.
   

New wound treatment protocol:

 

• When a new wound is discovered a foam dressing should be applied until the wound nurse has performed an assessment and made a treatment recommendation.

  • The dressing should be change and the wound cleansed with normal saline at least daily or prn if exudate capacity has been exceeded (>3/4 strike-through drainage).

• The wound nurse will assess the wound initially then routinely until healed.

• The wound nurse or designee will assess all full thickness and recalcitrant wounds (open >1 month) every 2 weeks and upon request.

• The Interdisciplinary Wound Team will assess the wound monthly until healed.

 

Debridement:

 

• If devitalized tissue is present in the wound bed a treatment will be ordered to facilitate debridement.​

  • Only selective debridement will be used at MCH as it is an established best practice.

  • Debridement therapies will be discontinued when the wound bed is clean and treatments will focus on proliferation.

  • If the wound nurse determines that healing has stalled due to the presence of a bio-film, debridement may be ordered despite the lack of devitalized tissue visualized in the wound bed.

  • A wound clinic referral will be generated by the wound care nurse if they determine that sharp debridement is indicated. Wound clinic referrals will be generated by the wound care nurse ONLY.

 

Post-sharp debridement protocol:

 

• Wounds that are sharply debrided will have an antimicrobial absorptive dressing in place for the first 24 hours after the procedure in accordance with best practices.
   

Bio-burden/localized inflammation:

 

• If the wound care nurse determines that healing has slowed or stalled due to an unfavorable level of bio-burden as evidenced by clinical signs of localized infection an antibacterial dressing may be recommended.

  • If devitalized tissue is present in the wound it should be adequately debrided per best practices.

  • Bactericidal dressing treatments should be limited to two weeks in duration to reduce the negative impact on healthy tissue per best practices.

Proliferation:

 

• When a wound is without devitalized tissue, treatment goals should promote tissue proliferation in the following ways.

  • Minimizing trauma- offload pressure, minimize dressing change related trauma

  • Maintain wound bed temperature- minimize dressing changes, limit exposure to cold environment.

  • Maintain favorable moisture balance- select dressings with longer wear time as appropriate for exudate to maintain moist healing environment, protect peri-wound with skin sealants.

  • Maximize nutrition- ensure patient has menu items they enjoy and is meeting calorie and protein recommendations per the registered dietician.
     

Negative Pressure Wound Therapy (NPWT):

 

• Negative Pressure Wound Therapy (NPWT) is an essential advanced wound healing therapy and will be utilized at MCH when determined to be appropriate for a patient.

• MCH may choose to utilize one of a variety of NPWT devices as technology advances.

• Determination of appropriateness of NPWT for a patient will be made by the wound care nurse in conjunction with the IWT.

• NPWT dressing changes will only be performed by a licensed nurse who has demonstrated competence as determined by the wound care nurse or designee.

• Refer to XIII-06 NPWT policy for further guidance.

 

Patients with Peripheral Vascular Disease:

 

• Patients with a history of arterial insufficiency should be follow by a vascular provider whenever possible.

  • Lower extremity compression will not be applied to any patient with a history of PAD unless a recent ABI has been performed showing adequate perfusion and there is a medical order present.

    • Therapeutic compression (40 mmHg at the ankle) will only be applied to patients with a recently documented ABI> 0.8.​

    • Modified compression (up to 23 mmHg at the ankle) will only be applied to patients with a recently documented ABI 0.6-0.8

    • No lower extremity compression will be applied to patients with a history of PAD who do not have a recent ABI documented or have a recent ABI less than or equal to 0.5.

  • Dry, distally located, hypo-perfused wounds with adherent devitalized tissue should not be debrided unless infected (especially when located on the heel) due to the increased risk of osteomyelitis.

• Patients with a history of chronic venous stasis should be follow by a vascular provider whenever possible.

  • Patients with depended edema secondary to chronic venous stasis and a normal ABI, should have therapeutic compression applied whenever out of bed.

    • Modified compression should be utilized as appropriate per ABI results.

  • Dressing treatments for patients with venous ulcers should focus on exudate management, autolytic debridement and facilitating reuptake of venous blood via compression.

• Patients with a history of Diabetic foot ulcers should be follow by a podiatrist whenever possible.

  • Patients with diabetes should have the skin inspected for breakdown at least weekly.

  • Treatments for patients with diabetic foot ulcers should include adequate offloading, debridement as appropriate, frequent assessment for infection and moist wound healing.

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Other dermatologic issues:

 

• Other dermatologic issues such as autoimmune disorders, unresolved skin hypersensitivities and malignancy will be referred to a dermatologist for evaluation.

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Director of Nursing

Approved by: Nursing Policy/Procedure Committee

Date Approved: 7/1/2014 Revision Date: 10/1/2019, 10/01/2023, 03/04/2025