promoting healthy skin - qut...department of veterans affairs’ clients who were predominantly aged...

healthy skinChampions for Skin Integrity

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This project is funded by the Australian Government Department of Health and Ageing under the Encouraging Better Practice in Aged Care (EBPAC) program

CSI Guide and Resource Pack


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About this guide

Congratulations on wanting to become a Champion for Skin Integrity (CSI).

New Champions for Skin Integrity embark on a journey with the ultimate goal of improving evidence–based wound management and reducing the prevalence and severity of wounds of people under their care. This guide is designed to help you on that journey. It not only provides you with information on how to develop as a CSI but includes a comprehensive range of resources that will help you in that role.

The guide is structured in six sections – each section builds on the knowledge gained from the preceding sections.

Section 1 provides a background to the development of the CSI model of wound care and the seven steps you need to take to become a fully fledged CSI.

Section 2 explains the role of the CSI and the other health professionals and networks that work together to implement an evidence-based culture within your facility or organisation.

Section 3 is where you get to the nuts and bolts of wound management.

Included in this section is a comprehensive range of interactive and printed resource material. This material is aimed at a variety of audiences from the health professional to the carers and families of clients. The resource material can be photocopied directly from the guide or printed from the files stored on the CSI Resource CD at the back of the booklet.

Section 4 gives the new CSI the tools to carry out a skin integrity survey in their facility or organisation. A training package on using the data collection tools is available on the CSI Resource CD.

Section 5 gives you the meeting and education tools that will become necessary as your wound care network develops.

And finally

Section 6 provides a list of references of the background material contained in this guide.

We hope you enjoy your journey and that this guide provides a useful roadmap for you to reach you ultimate goal – to become a Champion for Skin Integrity.

Champions for Skin Integrity CSI Guide and Resource Pack Authors: Edwards H, Gibb M, Finlayson K, Jensen R. 2013 Brisbane: Queensland University of Technology. E: [email protected]

ISBN 978-1-921897-78-8


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Table of contents

1. Introduction and Background

1.1 Introduction

1.2 Background

1.3 The Champions for Skin Integrity Model of wound care

1.4 The Seven Steps to Becoming a Champion for Skin Integrity

2 Role Definitions

2.1 Champions for Skin Integrity (CSI)

2.2 Multidisciplinary Wound Care Networks

2.3 Link Clinicians

3 Wound Care Resources

3.1 Promoting Healthy Skin - Self-education DVD

3.2 Printed Wound Management Resource Material

3.2.1 Guidelines Summaries

3.2.2 Tip sheets

3.2.3 Flow Charts

3.2.4 Brochures

3.3 Information links

3.3.1 Wound Care Organisations

3.3.2 Evidence-based Guidelines

3.3.3 Scholarships

3.4 CSI Discussion Group Packages

3.5 Skin Tear Management Package

4 Data Collection Tool

4.1 Skin Integrity Survey

5 Meeting and Education Support Tools

5.1 Meeting Support Tools

5.2 Education Support Tools

6 References


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1.1 Introduction

Congratulations on wanting to become a Champion for Skin Integrity. As a Champion for Skin Integrity (CSI) you will play a valuable role in ensuring the implementation of sustainable evidence-based practice in wound management within your organisation. You will also help others in your organisation to incorporate strategies to preserve skin integrity through the application of evidence-based practice to assessment, prevention and management of common wound types like skin tears, leg ulcers and pressure injuries.

The CSI resource kit has been provided to assist you in this role and to lead implementation of evidence into everyday clinical practice. The resource kit consists of two elements:

• CSI Guide and Resource Pack

• Wound Dressing Guide

We hope that you enjoy participating in this exciting role.

1 Introduction and Background

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1.2 Background

The incidence of skin tears, pressure injuries, chronic leg ulcers and diabetic foot ulcers increases with age2-5 and this therefore, is a serious issue for older adults. In particular, skin tears are common amongst frail older or disabled persons. Risk factors include visual impairment, impaired mobility or balance, altered mental status, or changes in skin condition due to medications e.g. steroids, anticoagulants.5

In Australia, Everett and Powell6 found skin tears constituted 41% of known wounds amongst residents (with an average age of 80 years) in a 347 bed long-term care facility, and on average, 22 skin tears occurred each month.6 Similarly in an audit conducted by a community nursing organisation in November 1999 and April 2000 amongst Department of Veterans Affairs’ clients who were predominantly aged over 70 years or more, skin tears were found to account for 20% of all known wounds.5

Although a large number of evidence-based guidelines exist for prevention and management of wounds, studies have found a substantial gap exists between the evidence and timely assessment and best practice management of wounds, both in Australia and overseas.1


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Pressure injury prevalence has been reported at 16–23% in combined hospital and residential aged care populations7,8; and chronic leg ulcers affect 1–3% of population aged over 60 years, with incidence increasing up to 5-10% of the over 80 years age group.2,4

Chronic wounds are a significant cause of pain, decreased functional ability and poor quality of life, as well as a burden on carers and health system resources.2,9,10 Older adults and residents of aged care facilities are at high risk of suffering with skin tears, pressure injuries and chronic wounds; and are thus in urgent need of appropriate evidence-based assessment, prevention and management strategies.

1.3 The Champions for Skin Integrity Model of wound care

As part of the Department of Health and Ageing’s Encouraging Best Practice in Residential Aged Care Program (EBPRAC), in 2009-2010 the Queensland University of Technology (QUT) led a

consortium of seven Residential Aged Care Facilities (RACFs) in a project to promote evidence-based wound management and improved skin integrity for residents in aged care facilities

Research on models of care for chronic wounds indicates that the provision of evidence-based wound care, preventive strategies, chronic disease management and improved communication and educational opportunities among health professionals can significantly improve wound healing and reduce the risk of recurrence of wounds.11,13,14

The project found a significant number of aged care residents suffer chronic wounds and/or are susceptible to skin tears. The implementation of the CSI model was successful in achieving increased implementation of evidence-based wound management and decreased prevalence and severity of wounds in residents.

In 2012, the Commonwealth Department of Health and Ageing funded a national dissemination or roll-out of the Champions for Skin Integrity model of wound care.

The average duration of chronic leg ulcers is around 12–13 months,11,12 60–70% of those with a chronic leg ulcer have recurrent ulcers,10 24% are hospitalised because of the ulcers and most people suffer from the condition for an average of 15 or more years.12

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1.4 The Seven Steps to Becoming a Champion for Skin Integrity

Step 1

The first and arguably most important step is to identify a champion within your organisation. This person does not need to be an expert in wound management. Rather it would be someone who is committed to best practice wound management in your organisation and has the ability to influence and lead organisational change that results in improved wound management and prevention outcomes. It is anticipated that this clinical leader would train a CSI team in the use of the resource kit. Over time they become a valuable resource on wound management issues and a central knowledge source for staff at all levels, residents, relatives and carers, as well as allied health professionals to access for advice. They would become a “Champion for Skin Integrity”.

Step 2To gain an understanding of the role of a champion and associated networks, new champions can refer to Section 2 of this booklet on role definitions and explanations.

Step 3Potential CSIs can then complete the “Promoting Healthy Skin” self education DVD to update their knowledge of evidence-based wound management.

Step 4The next step is to review the resource materials contained in Section 3, in addition to the Wound Dressing Guide, which provides guidance on use of commonly available wound dressings.

Step 5After becoming familiar with the content and variety of resources available in the kit they would then go to Section 4 to review the Skin Integrity Survey tool and training package, and their potential use. This tool could be used on a regular basis to determine the prevalence and/or incidence of wounds and their management.

Step 6After reviewing the roles and resources, completing the education materials contained within the kit, and potentially undertaking a skin integrity audit or a review of the organisation’s/facility’s needs, the CSIs, in consultation with their team of CSIs and Wound Care Network members, may identify an area of need within their organisation/facility. To address such a need it is suggested to prepare an action plan. In the first instance — start small. For example, introduce one measure such as moisturising skin twice daily.

It is vital that the action plan receive support from senior management.

Step 7As the model is implemented the Meeting and Education Support tools contained in Section 5 would become useful.

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2.1 Champions for Skin Integrity (CSI)

What is a Champion for Skin Integrity or CSI?

A Champion for Skin Integrity or CSI can be best described as a health professional with a strong interest in wound management, who is confident in their ability to lead and act as a resource person for other staff members and who is willing to form a direct link with a Wound Care Network within their local organisation and with external Link Clinicians.

Who can be a CSI?

Ideally the CSI will: • Be a registered or enrolled nurse;

however care workers, quality assurance officers or other clinical leaders may participate as CSI team members.

• Hold qualifications and/or have a strong interest in maximising opportunities to advance self knowledge and skills in wound management and be willing to support other care staff.

• Have local credibility within their organisation.

The CSI Resource kit has been developed to help CSIs in their role and as new information is developed you

can build on the information already contained in this kit. As a CSI(s) you will be able to provide advice and consultation for other staff and this resource kit will help the future development of new CSIs.

CSI Role Responsibilities

• Implement evidence-based strategies and care practices for assessment, prevention and management of wounds and preserving skin integrity as part of daily practice.

• Provide a first point of contact and act as a resource person for advice for other staff members on evidence-based wound management.

• Facilitate or contribute to educational in-services for staff members within your organisation.

• Enhance knowledge, skills and attitudes of care staff towards skin integrity and ultimately improve skin integrity for older adults.

• Form a direct link and leadership role with the Wound Care Network within their local organisation and external Link Clinicians.

• Coordinate or participate in regular CSI team meetings, with set agenda, reporting on progress and planned action steps documented.

2 Role Definitions

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The benefits of having CSIs

• Organisations will be assured they have a staff member(s) who has a sound knowledge of evidence-based practice and skills in wound care.

• Organisations will have a staff member(s) who is willing to be a key point of contact and resource for staff caring for clients with skin integrity issues and who is proactive in disseminating knowledge to others.

• Reduced prevalence of wounds and improved healing outcomes.

• Improved continuity in wound management interventions.

• Improved relationships and communication with the community through liaising with other health care professionals, clients and families.

CSI Role Descriptions for different categories of care staffThe following CSI role descriptions are included in this booklet. They can be photocopied directly from this booklet or alternatively can be printed from the relevant files included on the CSI resource files CD.

• How to Champion Skin Integrity as a Registered Nurse (RN)

• How to Champion Skin Integrity as an Enrolled Nurse (EN)

• How to Champion Skin Integrity as an Personal Care Worker (PCW)

Champions for Skin Integrity

How to champion skin integrity as a Registered Nurse (RN)

Promoting ‘Skin Integrity’ means we aim to maintain intact, healthy skin able to perform its normal functions.

Act as a resource person and be a key point of contact for staff and management

Role model best practice

Implement evidence-based care for assessment and management of wounds and preserving skin integrity

Advance self knowledge of wound care

Facilitate or contribute to educational in-services for staff members

Enhance knowledge, skills and attitudes of staff towards skin integrity

Form direct links with external link clinicians


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How to champion skin integrity as an Enrolled Nurse (EN)


Act as a resource person or contact person for care workers


Support care staff


Attend educational opportunities

Report any issues causing skin problems


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How to champion skin integrity as a Personal Care Worker (PCW)


Moisturise clients’ skin twice daily

Encourage a healthy diet for clients

Encourage 6-8 glasses per day of fluids for clients

Use correct lifting/transferring techniques

Follow turning schedules as necessary

Report any skin problems of clients to EN/RN




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How to champion skin integrity as a Registered Nurse (RN)


Act as a resource person and be a key point of contact for staff and management



Advance self knowledge of wound care

Facilitate or contribute to educational in-services for staff members

Enhance knowledge, skills and attitudes of staff towards skin integrity

Form direct links with external link clinicians


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How to champion skin integrity as an Enrolled Nurse (EN)


Act as a resource person or contact person for care workers


Support care staff





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How to champion skin integrity as a Personal Care Worker (PCW)


Moisturise clients’ skin twice daily

Encourage a healthy diet for clients

Encourage 6-8 glasses per day of fluids for clients

Use correct lifting/transferring techniques

Follow turning schedules as necessary

Report any skin problems of clients to EN/RN




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2.2 Multidisciplinary Wound Care Networks

What is a Multidisciplinary Wound Care Network or MWCN?

A Multidisciplinary Wound Care Network (MWCN) can provide a valuable and sustainable resource within your organisation. The aim is to form a network which includes members from all disciplines who have an input to wound management within the broader context and environment of your organisation. Network members may include (but are not limited to) senior managers, finance officers, quality improvement coordinators, nursing representatives, care workers’ representatives, medical representatives, clients and/or family representatives, occupational/physiotherapists, dieticians, podiatrists and manual handling instructors. Each network will be unique according to the context of each organisation.

Why is a MWCN important?

• Coming together as a team combines the specific strengths of each discipline to focus on coordinated wound management strategies. Evidence has shown effective interdisciplinary teams decrease costs, improve client satisfaction and reduce morbidity, while improving overall health care worker satisfaction and professional relationships.

• Standard 1 of the AWMA Standards for Wound Management recognises and respects the contribution, knowledge and skills of members of the interdisciplinary team.

• A MWCN encourages identification of issues and actions that need to be taken, thus supporting best practice in wound care.

2.3 Link Clinicians

What is a Link Clinician?

A Link Clinician can be best described as a health professional that has an interest and expertise in wound management. The Link Clinician will be a valuable resource person within the community, who is willing to provide support and guidance to the identified Champions for Skin Integrity (CSI) at their local organisation, if required.

Who can be a Link Clinician?

Link Clinicians can be local health professionals who currently visit or who are external to your organisation. Link Clinicians who are practising within the local community can be identified and invited to be part of this important support network (e.g. from a RACF or local hospital, wound care nurse or stomal therapy nurse, occupational therapists, dieticians, podiatrists, domiciliary nurses, general practitioners, practice nurses, nurse practitioners).

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Ideally these Link Clinicians should have:• A special interest and enthusiasm in

wound management and a willingness to share their expertise with others.

• Expertise, good knowledge and skills related to wound management.

How will a Link Clinician work?

It is envisaged the Link Clinicians’ role may involve the following:

• A willingness to form a direct link with the Champions for Skin Integrity (CSI) and Wound Care Network within your local organisation.

• Acting as a resource person and be willing to provide skin integrity support and guidance to the CSI staff member and organisation if required.

• Consultation with CSIs on challenging skin integrity issues, so that information can be disseminated back to the clinical area within the organisation.

• Network involvement through periodic attendance at meetings, where ideas and new developments in wound management can be discussed.

What are the benefits of having Link Clinicians?

• Link Clinicians establish and formalise a broader Wound Care Network within the local community or region.

• Link Clinicians can provide greater access for CSIs to skin integrity expertise.

• Close relationships with Link Clinicians allows for the provision and dissemination of educational information and change management strategies for skin integrity, collaboratively with CSIs.

• A broader network of expertise will improve delivery of evidence-based practice for assessment, management and prevention of wounds.

• Enhanced quality of care provided to older adults.

• Improved skin integrity for clients.

• Use of Link Clinicians demonstrates to other organisations that they can build strength and capacity by using local resources.

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A broad range of wound management resources were developed during the first project and have been updated in 2013 to reflect the latest evidence. These resources, both interactive and print, provide a valuable range of materials that can be used for educational and practice purposes.

Samples of all resources are included in this booklet.

3.1 Promoting Healthy Skin Self-education DVD

An easy to use, computer-based skin care and wound management self-education package, called “Promoting Healthy Skin”, was developed during the first project and has been updated in 2013. This comprehensive package covers the assessment, management and prevention of the commonly encountered wounds. It is targeted to a wide audience of learners who have to deal with wounds. It is written to a DVD for convenient use.

The Promoting Healthy Skin DVD includes 8 separate interactive education modules covering Skin Care, Skin Tears, Venous Leg Ulcers, Arterial Leg Ulcers, Diabetic Foot Ulcers, Pressure Injuries, Wound Care, and Finding Evidence. In addition, the DVD includes the wound care resources included in this booklet as well as demonstration videos and images. Users can track their understanding by completing the quizzes at the end of each module.

A Promoting Healthy Skin DVD has been included in the booklet. The DVD self initiates when loaded onto the computer. Additional DVDs can be created by copying/burning the files from this DVD to a new DVD.

3 Wound Care Resources

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Nutrition and Wound Healing

For this summary, all recommendations have had their levels of evidence classified using the National Health and Medical Research Council levels of evidence, as follows:

Level I Evidence from a systematic review or meta-analysis of at least two level II studies

Level II Evidence from a well designed randomised controlled trial (for interventions), or a prospective cohort study (for prognostic studies)

Level III Evidence from non-randomised studies with some control or comparison group (pseudo-randomised controlled trial; non-randomised experimental trial, cohort study, case-control study, time series studies with a control group; historical control study, retrospective cohort study)

Level IV Evidence from studies with no control or comparison group

An additional rating of Expert Opinion (EO) has been added, for guideline recommendations which are consensus statements provided by a National or International Panel of experts in the area.

This is a summary of guidelines from the following sources, which should be accessed for further details as required:

1. Australian Wound Management Association, Standards for wound management. 2nd ed 2010, Osborne Park, WA: Cambridge Media. www.awma.com.au/publications/2011_standards_for_wound_management_v2.pdf

2. Trans Tasman Dietetic Wound Care Group, Evidence based practice guidelines for the dietetic management of adults with pressure injuries. Review 1: 2011. http://daa.asn.au/wp-content/uploads/2011/09/Trans-Tasman_Dietetic-Wound-Care-Group-Pressure-Injury-Guidelines-2011.pdf

3. Dorner B, Posthauer M, Thomas D, National Pressure Ulcer Advisory Panel, The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel White Paper 2009. www.ncbi.nlm.nih.gov/pubmed/19521288

4. Australian Wound Management Association, Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury 2012, Osborne Park, WA: Cambridge Media www.awma.com.au/publications/2012_AWMA_Pan_Pacific_Guidelines.pdf

5. Wilkinson E: Oral zinc for arterial and venous leg ulcers. Cochrane Database of Systematic Reviews 2012. Issue 8, CD001273.

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This summary has been developed for health professionals caring for clients with impaired skin integrity or those at risk of loss of skin integrity. Assessment and management of skin integrity should be undertaken by health professionals with expertise in the area.


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Wound Care








1. World Union of Wound Healing Societies. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd 2004. www.woundsinternational.com/pdf/content_39.pdf

2. Australian Wound Management Association. Standards for wound management. 2nd ed. Osborne Park, WA: Cambridge Media 2010. www.awma.com.au/publications/2011_standards_for_wound_management_v2.pdf

3. The Wound Healing and Management Node Group. Chronic wound management. (JBI) Best Practice: 2011. http://connect.jbiconnectplus.org

4. Australian Wound Management Association. Position Document: Bacterial impact on wound healing: From contamination to infection. AWMA 2011. www.awma.com.au/publications/2011_bacterial_impact_position_1.5.pdf

5. Hopf H et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair and Regeneration 2006. 14(6): 693-710. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2006.00177.x/pdf

6. World Union of Wound Healing Societies. Principles of best practice: Wound exudate and the role of dressings. A consensus document. London: MEP Ltd 2007. www.woundsinternational.com/pdf/content_42.pdf

7. Medical Advisory Secretariat. Community-based care for chronic wound management: An evidence-based analysis. Ontario Health Technology Assessment Series 2009. 9(18). www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_smcc_wound_20091019.pdf

8. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database of Systematic Reviews 2012(2). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003861.pub3/pdf

9. Whitney J et al. Guidelines for the treatment of pressure ulcers. Wound Repair and Regeneration 2006. 14(6): 663-679. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2006.00175.x/pdf

10. Best Practice Statement: The use of topical antiseptic/antimicrobial agents in wound management. 2nd ed. Wounds UK 2011. www.wounds-uk.com/best-practice-statements

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These guidelines have been developed for health professionals caring for clients with wounds. Assessment and management of wounds should be undertaken by health professionals with expertise in the area.


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Pressure Injuries








1. Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Osborne Park, WA: Cambridge Media 2012. http://www.awma.com.au/publications/2012_AWMA_Pan_Pacific_Guidelines.pdf

2. Association for the Advancement of Wound Care. Association for the Advancement of Wound Care guideline of pressure ulcer guidelines. Malvern, PA: AAWC 2010. http://www.guidelines.gov/content.aspx?id=24361

3. Stechmiller J et al. Guidelines for the prevention of pressure ulcers. Wound Repair and Regeneration 2008. 16: 151-168. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2008.00356.x/pdf

4. Wound Ostomy and Continence Nurses Society. Guideline for prevention and management of pressure ulcers. Mount Laurel, NJ: WOCN 2010. http://guideline.gov/content.aspx?id=23868

5. Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. (Revised). Toronto, ON: RNAO 2011. http://rnao.ca/sites/rnao-ca/files/Risk_Assessment_and_Prevention_of_Pressure_Ulcers.pdf

6. National Institute for Clinical Excellence. The use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. London: Royal College of Nursing 2004. http://www.ncbi.nlm.nih.gov/books/NBK48950/pdf/TOC.pdf

7. Royal College of Nursing. The management of pressure ulcers in primary and secondary care: A clinical practice guideline. London: RCN &NICE 2005. http://www.rcn.org.uk/__data/assets/pdf_file/0017/65015/management_pressure_ulcers.pdf

8. Hadwen G. Pressure area care: Prevention. (JBI) Best Practice: 2011. http://connect.jbiconnectplus.org

9. Whitney J et al. Guidelines for the treatment of pressure ulcers. Wound Repair and Regeneration 2006. 14: 663-679. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2006.00175.x/pdf

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These guidelines have been developed for health professionals caring for clients with or at risk of pressure injuries. Assessment, management and prevention of pressure injury should be undertaken by health professionals with expertise in the area.


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Diabetic Foot Ulcers








1. Steed DL et al. Guidelines for the treatment of diabetic ulcers. Wound Repair and Regeneration 2006.14:680-692. www3.interscience.wiley.com/cgi-bin/fulltext/118605280/PDFSTART

2. Steed DL et al. Guidelines for the prevention of diabetic ulcers. Wound Repair and Regeneration 2008. 16:169-174. www3.interscience.wiley.com/cgi-bin/fulltext/119413543/PDFSTART

3. National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes. Melbourne Australia 2011. http://t2dgr.bakeridi.edu.au/LinkClick.aspx?fileticket=anrL23t3ADw%3d&tabid=172

4. Scottish Intercollegiate Guidelines Network, Management of diabetes. A national clinical guideline. Edinburgh, Scotland: SIGN 2010. www.sign.ac.uk/pdf/sign116.pdf

5. Registered Nurses’ Association of Ontario, Assessment and Management of Foot Ulcers for People with Diabetes. Toronto, Ontario: RNAO 2005. http://rnao.ca/bpg

6. Botros M et al. Best practice recommendations for the prevention, diagnosis and treatment of diabetic foot ulcers: Update 2010. Wound Care Canada 2010. 8:6-70. http://cawc.net/images/uploads/resources/BestPracticeDFU2010E.pdf

7. McIntosh A et al. Prevention and Management of Foot Problems in Type 2 Diabetes: Clinical Guidelines and Evidence. Sheffield: National Institute for Health and Clinical Excellence 2003. www.nice.org.uk/nicemedia/pdf/ CG10fullguideline.pdf

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These guidelines have been developed for health professionals caring for clients with diabetic foot ulcers. Diagnosis of the aetiology of a leg or foot ulcer should be undertaken by health professionals with expertise in the area.


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3.2 Printed Wound Management Resource Material

CSIs need a large range of printed wound management resource material to effectively carry out their role. This material provides information for health care professionals and staff at all levels, clients, family and carers.

3.2.1 Guidelines SummariesThe primary role of a CSI is to foster an evidence-based culture for wound management within the organisation. The following evidence-based guidelines summaries provide a compilation of the latest evidence-related to wound management (as at 2013). CSIs may use the summaries to check recommendations and references on evidence-based wound care. They could also form the basis of educational interventions with other staff within the organisation.

• Skin Care

• Skin Tears

• Venous Leg Ulcers

• Arterial Leg Ulcers

• Diabetic Foot Ulcers

• Pressure Injuries

• Wound Care

• Nutrition and Wound Healing

The following print resources can be photocopied directly from this booklet or alternatively can be printed from the relevant files included on the CSI resource files CD. Two different files of each print resource is available on the CD. The ones with LocalPrinter included in the filespec can be printed to the local printer connected to your PC. The ones with CommercialPrinter included in the file spec can be sent to a commercial printer for a professional output.

Arterial Leg Ulcers








1. Scottish Intercollegiate Guidelines Network, Diagnosis and management of peripheral arterial disease: A national clinical guideline. 2006, Edinburgh: SIGN. www.sign.ac.uk

2. Hopf H. et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair and Regeneration, 2006. 14:693-710.

3. National Clinical Guideline Centre, Lower limb peripheral arterial disease. Diagnosis and management. NICE Clinical Guideline 147, 2012: London. http://publications.nice.org.uk

4. Hopf H. et al. Guidelines for the prevention of lower extremity arterial ulcers. Wound Repair and Regeneration, 2008. 16:175-188.

5. Nelson E., Bradley M. Dressings and topical agents for arterial leg ulcers. Cochrane Database of Systematic Reviews, 2007. 1: CD001836.

6. Registered Nurses’ Association of Ontario, Assessment and management of foot ulcers for people with diabetes. 2005. http://rnao.ca/bpg

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These guidelines have been developed for health professionals caring for clients with arterial leg ulcers. Diagnosis of the aetiology of a leg ulcer should be undertaken by health professionals with expertise in the area.


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Venous Leg Ulcers







This is a summary of guidelines and evidence from the following sources, which should be accessed for further details as required:

1. Royal College of Nursing, Clinical practice guidelines: The management of patients with venous leg ulcers. 2006, London: RCN Institute, Centre for Evidence based Nursing, University of York. www.rcn.org.uk/development/practice/clinicalguidelines/venous_leg_ulcers

2. Registered Nurses’ Association of Ontario, Assessment and Management of Venous Leg Ulcers. March 2004 ed. Registered Nurses’ Association of Ontario 2004, Toronto, Ontario: RNAO. http://rnao.ca/bpg/guidelines/assessment-and-management-venous-leg-ulcers

3. Australian Wound Management Association, Austalian and New Zealand Clinical Practice Guidelines for Prevention and Management of Venous Leg Ulcers, 2011, AWMA: Barton. ACT. www.awma.com.au/publications/publications.php#vlug

4. Scottish Intercollegiate Guidelines Network, Management of chronic venous leg ulcers. A national clinical guideline, 2010, SIGN: Edinburgh. www.sign.ac.uk/guidelines/fulltext/120/index.html

5. Moffatt CJ, Edwards L, Collier M et al., A randomised controlled 8-week crossover clinical evaluation of the 3M Coban 2 Layer Compression System versus Profore to evaluate the product performance in patients with venous leg ulcers. International Wound Journal 2008, 5:267-279.

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These guidelines have been developed for health professionals caring for clients with venous leg ulcers. Diagnosis of the aetiology of a leg ulcer as venous should be undertaken by a health professional with expertise in the area.


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Skin Tears








1. Ayello E, Sibbald R, Preventing pressure ulcers and skin tears, in Evidence-based geriatric nursing protocols for best practice, Capezuti E et al., Editors. 2008, Springer Publishing Company: New York. 403-29.

2. LeBlanc K, Baranoski S: Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Advances in Skin & Wound Care 2011, 24:2-15.

3. Ratliff C, Fletcher K: Skin Tears: A review of the evidence to support prevention and treatment. Ostomy Wound Management 2007, 53. www.o-wm.com/article/6968

4. Carville K, Lewin G, Newall N et al.: STAR: A consensus for skin tear classification. Primary Intention 2007, 15:18-28.

5. Joanna Briggs Institute: Topical skin care in aged care facilities. Best Practice 2007, 11. http://connect.jbiconnectplus.org/ ViewSourceFile.aspx?0=4346

6. Best Practice Statement: Care of the Older Person’s Skin Wounds UK 2012; 2nd Edition: www.woundsinternational.com/pdf/ content_10608.pdf.

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Skin Care







This is a summary of recommendations from the following sources, which should be accessed for further details as required:

1. Best Practice Statement: Care of the Older Person’s Skin. 2nd ed. 2012: Wounds UK. www.woundsinternational.com/pdf/ content_10608.pdf

2. Gray M et al.: Incontinence-associated dermatitis: A comprehensive review and update. Journal of Wound, Ostomy, and Continence Nursing 2012, 39:61-74.

3. The Joanna Briggs Institute: Topical skin care in aged care facilities. Best Practice: evidence-based information sheets for health professionals 2007, 11:1-4. http://connect.jbiconnectplus.org/ ViewSourceFile.aspx?0=4346

4. Australian Wound Management Association (AWMA), Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury 2012, Cambridge Media Osborne Park, WA. www.awma.com.au/publications/ 2012_AWMA_Pan_Pacific_Guidelines.pdf

5. Stechmiller J et al.: Guidelines for the prevention of pressure ulcers. Wound Repair Regeneration 2008, 16:151-168. http://onlinelibrary.wiley.com/doi/10.1111/ j.1524-475X.2008.00356.x/pdf

6. Hodgkinson B, Nay R, Wilson J: A systematic review of topical skin care in aged care facilities. Journal of Clinical Nursing 2006, 16:129-136. http://onlinelibrary.wiley.com/doi/10.1111/ j.1365-2702.2006.01723.x/pdf

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Skin Care







This is a summary of recommendations from the following sources, which should be accessed for further details as required:

1. Best Practice Statement: Care of the Older Person’s Skin. 2nd ed. 2012: Wounds UK. www.woundsinternational.com/pdf/ content_10608.pdf

2. Gray M et al.: Incontinence-associated dermatitis: A comprehensive review and update. Journal of Wound, Ostomy, and Continence Nursing 2012, 39:61-74.

3. The Joanna Briggs Institute: Topical skin care in aged care facilities. Best Practice: evidence-based information sheets for health professionals 2007, 11:1-4. http://connect.jbiconnectplus.org/ ViewSourceFile.aspx?0=4346

4. Australian Wound Management Association (AWMA), Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury 2012, Cambridge Media Osborne Park, WA. www.awma.com.au/publications/ 2012_AWMA_Pan_Pacific_Guidelines.pdf

5. Stechmiller J et al.: Guidelines for the prevention of pressure ulcers. Wound Repair Regeneration 2008, 16:151-168. http://onlinelibrary.wiley.com/doi/10.1111/ j.1524-475X.2008.00356.x/pdf

6. Hodgkinson B, Nay R, Wilson J: A systematic review of topical skin care in aged care facilities. Journal of Clinical Nursing 2006, 16:129-136. http://onlinelibrary.wiley.com/doi/10.1111/ j.1365-2702.2006.01723.x/pdf

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These guidelines have been developed for health professionals caring for clients with impaired skin integrity or those at risk of loss of skin integrity. Assessment and management of skin integrity should be undertaken by health professionals with expertise in the area.


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Skin Care [2 of 2]

Assessment

1. All clients should have skin integrity assessed on admission and at regular intervals 1 (EO)

Management and Prevention

2. Structured documented protocols for skin care can help maintain skin integrity for those with incontinence 2 (III)

3. Avoid dryness or maceration of skin (i.e. moisturise dry skin, avoid sustained contact of skin with fluids, encourage continence) 2 (EO)

4. An emollient soap substitute should be used for dry or vulnerable skin 1 and is more effective than a non-emollient soap in preventing skin tears 2 (IV)

5. Skin cleansers (e.g. no-rinse cleansers, foam cleansers) are more effective than soap and water for prevention of incontinence-related skin problems 1,3 (III)

6. Dry skin thoroughly after washing. Dry skin by patting, not rubbing 1 (EO)

7. Moisturise dry skin at least twice daily 1 (EO)

8. Gently smooth on the moisturiser or barrier cream in the direction of body hair, don’t rub 1 (EO)

9. A no-sting barrier film or hydrogel barrier cream may have improved skin integrity outcomes in comparison to petroleum based ointments or creams in patients with incontinence 2 (IV)

10. Protect skin exposed to friction 4 (EO)

11. Avoid vigorous massage over bony prominences 5 (III)

12. Avoid overheating skin (avoid plastic support surfaces, ensure regular turning schedules do not exceed 2 hourly intervals for those on basic mattresses) 4 (EO)

13. Employ correct lifting and manual handling techniques, including use of lift sheets or devices to transfer clients 4,5 (IV)

14. Disposable incontinence products may be better at preventing skin problems than non-disposable products 6 (III)

15. Maintain optimal nutritional status with adequate calories, protein, carbohydrates, fat and vitamins and minerals 5 (II)


Skin Tears








1. Ayello E, Sibbald R, Preventing pressure ulcers and skin tears, in Evidence-based geriatric nursing protocols for best practice, Capezuti E et al., Editors. 2008, Springer Publishing Company: New York. 403-29.

2. LeBlanc K, Baranoski S: Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Advances in Skin & Wound Care 2011, 24:2-15.

3. Ratliff C, Fletcher K: Skin Tears: A review of the evidence to support prevention and treatment. Ostomy Wound Management 2007, 53. www.o-wm.com/article/6968

4. Carville K, Lewin G, Newall N et al.: STAR: A consensus for skin tear classification. Primary Intention 2007, 15:18-28.

5. Joanna Briggs Institute: Topical skin care in aged care facilities. Best Practice 2007, 11. http://connect.jbiconnectplus.org/ ViewSourceFile.aspx?0=4346

6. Best Practice Statement: Care of the Older Person’s Skin Wounds UK 2012; 2nd Edition: www.woundsinternational.com/pdf/ content_10608.pdf.

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These guidelines have been developed for health professionals caring for clients with impaired skin integrity or those at risk of loss of skin integrity. Assessment, management and prevention of skin tears should be undertaken by health professionals with expertise in the area.


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Skin Tears [2 of 2]

Assessment

1. All clients should have a risk assessment for skin tears on admission 1,2 (EO)

2. Risk factors include: - limited mobility and use of wheelchairs or other mobility aids 2,3 (IV)

- cognitive impairment 2,3 (IV) - poor nutrition 2,3 (IV) - polypharmacy 2,3 (IV) - sensory loss 2,3 (IV)

3. A recognised skin tear assessment and classification system should be utilised 1,2,4

(EO)

4. Assess the size of the skin tear and document the assessment 1 (EO)

Management

5. Gently clean the wound 1,2,4 (EO)

6. Approximate any skin tear flap if possible 1-4 (EO)

7. Air or gently pat the skin dry 1 (EO)

8. Use non-adherent dressings 1,3 (EO)

9. Use tubular non-adhesive wraps, stockinettes or flexible netting to secure dressings rather than tape 1,3 (EO)

10. Place an arrow to indicate the direction of the skin tear on the dressing 1,3 (EO)

Prevention

11. A prevention protocol should be in place for clients identified as at risk for skin tears, including regular skin assessments 1-3 (EO)

12. An emollient soap substitute should be used for dry or vulnerable skin and is more effective than a non-emollient soap in preventing skin tears 1,3,5,6 (IV)

13. Moisturise skin at least twice daily 1,3,6 (EO)

14. Dry skin thoroughly after washing. Dry skin by patting, not rubbing6 (EO)

15. Gently smooth on the moisturizer or barrier cream in the direction of body hair, don’t rub6 (EO)

16. Pad wheelchair arms, footrests, bedrails, walking frames 1-3 (EO)

17. Provide adequate lighting to prevent bumping into furniture 1,3 (EO)

18. Long sleeves and pants should be worn to protect extremities 1-3 (EO)

19. Employ correct lifting and manual handling techniques 1-3 (EO)

20. Maintain optimal nutrition and hydration status 1,2 (EO)

Venous Leg Ulcers







This is a summary of guidelines and evidence from the following sources, which should be accessed for further details as required:

1. Royal College of Nursing, Clinical practice guidelines: The management of patients with venous leg ulcers. 2006, London: RCN Institute, Centre for Evidence based Nursing, University of York. www.rcn.org.uk/development/practice/clinicalguidelines/venous_leg_ulcers

2. Registered Nurses’ Association of Ontario, Assessment and Management of Venous Leg Ulcers. March 2004 ed. Registered Nurses’ Association of Ontario 2004, Toronto, Ontario: RNAO. http://rnao.ca/bpg/guidelines/assessment-and-management-venous-leg-ulcers

3. Australian Wound Management Association, Austalian and New Zealand Clinical Practice Guidelines for Prevention and Management of Venous Leg Ulcers, 2011, AWMA: Barton. ACT. www.awma.com.au/publications/publications.php#vlug

4. Scottish Intercollegiate Guidelines Network, Management of chronic venous leg ulcers. A national clinical guideline, 2010, SIGN: Edinburgh. www.sign.ac.uk/guidelines/fulltext/120/index.html

5. Moffatt CJ, Edwards L, Collier M et al., A randomised controlled 8-week crossover clinical evaluation of the 3M Coban 2 Layer Compression System versus Profore to evaluate the product performance in patients with venous leg ulcers. International Wound Journal 2008, 5:267-279.

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Venous Leg Ulcers [2 of 3]

Assessment

1. Assessment of leg ulcers and Doppler ABPI assessments should be undertaken by health professionals with training in this area 1-4 (IV)

2. Clients with a leg ulcer should be screened for arterial disease, including:

- examining pedal pulses - Doppler examination to check Ankle-Brachial Pressure Index is ≥0.8

- compression therapy is contraindicated if ABPI less than 0.7 or higher than 1.2. An ABPI over 1.2 is unreliable and indicates further investigation is necessary. Referral for ultrasound duplex scanning may be helpful if there is uncertainty 1,3,4 (II)

3. A Doppler reassessment should be undertaken:

- whenever starting compression therapy1

- whenever changing type of compression therapy1

- whenever an ulcer deteriorates1

- for reassessment every 3 months1 (III)

4. Measure ulcer area to monitor progress regularly, 3,4 every 4 weeks 1 (IV)

5. Referral to a specialist is needed when there is:

- uncertainty in diagnosis 3

- a low or high ABPI 1

- complex ulcers e.g. multiple aetiology such as arterial, rheumatoid disease 3

- signs of infection 3

- deterioration of ulcer 3

- failure to improve after 3 months 1,3,4 (EO)

Management

6. Where there are no contraindications, multilayer high compression bandage systems with adequate padding should be the first line of treatment for uncomplicated venous leg ulcers (ABPI ≥0.8)1,4

(I)

- Four layer compression bandage systems result in a shorter time to healing than short-stretch bandage systems4

(I)

- One study found a two-layer (Coban™ 2 Layer) compression bandage system as effective for healing as a four-layer bandage system5

(II)

- Contraindications include ulcers of other or mixed aetiology, peripheral vascular disease, heart disease, peripheral neuropathy and/or an ABPI <0.8 or >1.2 3

(EO)

7. Compression should be applied by a trained practitioner1-4 (IV)

8. Protective padding should be used over bony prominences when applying compression 2,3 (EO)

9. When using elastic high compression bandages, the ankle circumference should be more than or padded to 18cms 2

(EO)

10. Irrigate the ulcer with a neutral, non-irritating solution, e.g. warm tap water or saline 1-4 (IV)

11. If present, removal of necrotic and devitalised tissue should be undertaken through mechanical, sharp, autolytic or biological debridement3 (IV) Sharp debridement should only be undertaken by appropriately trained practitioners4 (EO)


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Venous Leg Ulcers [3 of 3]

12. EMLA® cream can reduce the pain associated with debridement when there are no contraindications3 ( I )

13. Dressings should be simple, low adherent, low cost1-4 and acceptable to the client1-3 ( I )

14. Dressings should maintain a moist wound-healing environment, manage wound exudate and protect the peri-ulcer skin 2,3 (II)

15. There is no evidence that any one dressing type is better than another 3,4 ( I )

16. Products that commonly cause skin sensitivity (e.g. lanolin, phenol alcohol, topical antibiotics) should not be used on leg ulcer clients 1,2

(EO)

17. There is insufficient evidence that - topical negative pressure (II)

- laser treatment (I) - therapeutic ultrasound (as opposed to ultrasound for debridement) ( I )

- electromagnetic therapy (II) - hyperbaric oxygen (II) - enzymatic debriding agents (II) - or skin grafting (II)

speeds healing of venous leg ulcers 1,3,4

18. Systemic antibiotics should not be used for ulcers that show no clinical signs of infection3 (II)

19. Appropriate client education (written and/or verbal) may lead to improvement in knowledge of their condition and concordance with its management 3

(EO)

20. Recommend leg elevation and progressive leg exercises as part of the management plan3 (EO)

21. Specialist leg ulcer clinics are recommended as the optimal community service 4 (II)

22. There is insufficient evidence to recommend aspirin4, (II)micronised purified flavanoid fraction4 (II)or mesoglycan4 (II)to increase healing rates. If there are no contraindications, pentoxifylline may promote healing 3,4 (II)

Prevention

23. After healing, use of compression therapy (for life) reduces ulcer recurrence rates.1-4 Class 3 compression (40mmHg and higher) is recommended if tolerated, otherwise the highest level of compression tolerated 1,2,4 (II)

24. Compression hosiery should be measured and fitted by a trained practitioner and replaced every six months2 (EO)

25. Other recommended strategies to prevent recurrence include:

- venous investigation and surgery3,4 ( I ) - regular follow-up and skin checks1,2 (EO) - skin care, lower limb exercise and elevation of the affected limb1-4 (EO)


Arterial Leg Ulcers








1. Scottish Intercollegiate Guidelines Network, Diagnosis and management of peripheral arterial disease: A national clinical guideline. 2006, Edinburgh: SIGN. www.sign.ac.uk

2. Hopf H. et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair and Regeneration, 2006. 14:693-710.

3. National Clinical Guideline Centre, Lower limb peripheral arterial disease. Diagnosis and management. NICE Clinical Guideline 147, 2012: London. http://publications.nice.org.uk

4. Hopf H. et al. Guidelines for the prevention of lower extremity arterial ulcers. Wound Repair and Regeneration, 2008. 16:175-188.

5. Nelson E., Bradley M. Dressings and topical agents for arterial leg ulcers. Cochrane Database of Systematic Reviews, 2007. 1: CD001836.

6. Registered Nurses’ Association of Ontario, Assessment and management of foot ulcers for people with diabetes. 2005. http://rnao.ca/bpg

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Arterial Leg Ulcers [2 of 3]

Assessment

1. All clients with a leg ulcer should be screened for arterial disease, including:

- examining pedal pulses - a Doppler Ankle Brachial Pressure Index (ABPI)

An ABPI less than 0.9 is indicative of arterial diseaseAn ABPI over 1.2 is unreliable and indicates further investigation is necessary. Referral for ultrasound duplex scanning may be helpful if there is uncertainty1-3 (EO)

2. Assessment of leg ulcers and Doppler ABPI assessments should be undertaken by health professionals with training in this area1, 3 (EO)

3. Signs of peripheral vascular disease include loss of hair, shiny or dry skin, mummified or dry and black toes, devitalised soft tissue with dry or wet crust, thickened toe nails, purple colour of limb in dependent position, or cool skin4 (II)

4. Referral to a specialist is needed when: - there is uncertainty in diagnosis - there is a low or high ABPI - patient has symptoms which limit lifestyle and quality of life (e.g. rest pain)

- complicated ulcers e.g. multiple aetiologies

- signs of infection - the ulcer appears ischemic1, 2 (EO)

Management

5. Restoration of blood flow by revascularisation is the intervention most likely to heal arterial leg ulcers. However, surgery must be considered in light of a patient’s co-morbidities2, 5 (II)

6. Adequate oxygenation of the wound environment will promote wound healing, and should be promoted through avoidance of smoking, dehydration, cold, stress and pain2 (III)

7. Topical antimicrobial dressings may be beneficial when wounds are chronically or heavily colonized2 (III)

8. In general, removal of necrotic and devitalised tissue should be undertaken through mechanical, sharp, autolytic or biological debridement2 (II)If dry gangrene or eschar is present, however, debridement should not be undertaken until arterial flow has been re-established2 (III)Sharp debridement should only be undertaken by health professionals with experience and training in the area6 (EO)

9. Dressings should be cost effective, acceptable to the client and able to be changed daily or less often where possible2 (II)

10. Dressings should: - maintain a moist wound-healing environment2 (II)

- however, dry gangrene or eschar is best left dry until revascularisation2 (II)

There is insufficient evidence to determine whether choice of topical agent/wound dressing material makes any impact on wound healing5 (EO)


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Arterial Leg Ulcers [3 of 3]

11. There is inadequate evidence that the application of topical negative pressure, (III)electrostimulation, (II)ultrasound, (III)intermittent pneumatic compression, (II)or topical oxygen therapy (III)speeds healing of arterial leg ulcers2

12. Hyperbaric oxygen therapy may be helpful in clients who are unable to be revascularised and whose ulcer is not healing2 (II)

Prevention

13. Reducing risk factors may reduce the risk of arterial ulcer development, including:

- cessation of smoking - maintaining control of diabetes mellitus

- controlling elevated lipids and hypertension

- taking anti-platelet therapy - controlling weight1-3 (II)

14. Exercise to increase arterial blood flow is helpful to prevent arterial ulcers2 (I)

15. Lower extremity protection is important for all clients with known or suspected peripheral arterial disease, including:

- foot protection with soft, conforming, proper fitting shoes, orthotics and offloading as necessary4 (II)

- leg protection to avoid injury4 (II) - protection of digits and heels in clients with decreased mobility with effective pressure relief devices e.g. foam or air cushion boots4 (II)

- extreme care is needed when cutting toenails, preferably undertaken by a podiatrist4 (II)

16. Passive warming of the extremity improves perfusion and may be of benefit in preventing arterial ulcers (e.g. warm socks, rugs, warm environment)4 (III)

17. Poor psychosocial status (i.e. psychiatric illness, living alone, alcohol abuse, malnutrition) is associated with a higher risk of arterial ulcers and should be addressed with a multidisciplinary care team4 (II)










1. Steed DL et al. Guidelines for the treatment of diabetic ulcers. Wound Repair and Regeneration 2006.14:680-692. www3.interscience.wiley.com/cgi-bin/fulltext/118605280/PDFSTART

2. Steed DL et al. Guidelines for the prevention of diabetic ulcers. Wound Repair and Regeneration 2008. 16:169-174. www3.interscience.wiley.com/cgi-bin/fulltext/119413543/PDFSTART

3. National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes. Melbourne Australia 2011. http://t2dgr.bakeridi.edu.au/LinkClick.aspx?fileticket=anrL23t3ADw%3d&tabid=172

4. Scottish Intercollegiate Guidelines Network, Management of diabetes. A national clinical guideline. Edinburgh, Scotland: SIGN 2010. www.sign.ac.uk/pdf/sign116.pdf

5. Registered Nurses’ Association of Ontario, Assessment and Management of Foot Ulcers for People with Diabetes. Toronto, Ontario: RNAO 2005. http://rnao.ca/bpg

6. Botros M et al. Best practice recommendations for the prevention, diagnosis and treatment of diabetic foot ulcers: Update 2010. Wound Care Canada 2010. 8:6-70. http://cawc.net/images/uploads/resources/BestPracticeDFU2010E.pdf

7. McIntosh A et al. Prevention and Management of Foot Problems in Type 2 Diabetes: Clinical Guidelines and Evidence. Sheffield: National Institute for Health and Clinical Excellence 2003. www.nice.org.uk/nicemedia/pdf/ CG10fullguideline.pdf

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Diabetic Foot Ulcers [2 of 3]

Assessment

1. Assess all clients with diabetes for the risk of developing a foot ulcer, including:

- screening for peripheral arterial disease (PAD), by identifying strong pedal pulses and measuring an Ankle Brachial Pressure Index (ABPI). An ABPI less than 0.9 indicates arterial disease. An ABPI over 1.2 is unreliable and requires further investigation1,2 ( I )

- screening for neuropathy, by testing with a 10g Semmes-Weinstein monofilament, in combination with clinical assessment of sensory, autonomic and motor changes3,4 (II)

2. Assessment of feet and diabetic foot ulcers should be undertaken by health professionals with training in this area5 (II)

3. Assess for risk factors (neuropathy, PAD, foot deformity) and classify foot ulcer risk as:low-risk: no risk factors and no history of foot ulcer/amputation; intermediate risk: one risk factor and no history of foot ulcer/amputation; or high risk: 2 or more risk factors and/or history of foot ulcer/amputation3,4 (III)

4. All Aboriginal and Torres Strait Island people with diabetes should be considered to be at high risk of developing foot complications3 (EO)

5. Consider use of ulcer grading systems (e.g. the University of Texas wound classification system) to predict probability of ulcer healing or complications3,6 (III)

6. Referral for medical or specialist assistance is needed when:

- there is uncertainty in diagnosis - there is a low or high ABPI - the client would benefit from revascularisation

- there are signs of infection or inflammation

- there is no progress in epithelialisation from the margin within two weeks of debridement and commencement of offloading therapy

- the wound can be probed to bone - the wound deteriorates or new ulceration occurs1,7 (II)

7. Document regularly wound characteristics and progress in wound healing;1 (II)including location, length, width, depth, ulcer bed characteristics, exudate, odour and peri-ulcer skin condition6 (EO)

Management

8. Care of a diabetic foot ulcer should be undertaken by a multidisciplinary team, including podiatrist, orthotist, GP, wound care nurse, and endocrinologist3,4 (III)

9. Consider use of remote expert advice with digital imaging for people living in remote areas who are unable to attend a multidisciplinary foot care service3 (III)

10. Offloading of pressure points is necessary. Acceptable methods to relieve pressure on the wound include crutches, walkers, wheelchairs, custom-made shoes or inserts, shoe modifications, custom relief orthotic walkers, diabetic boots, forefoot and heel relief shoes, total contact casts3,4,6 (I)


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Diabetic Foot Ulcers [3 of 3]

11. Adequate oxygenation of the wound environment will promote healing, and should be promoted through avoidance of dehydration, smoking, cold, stress and pain1 (III)

12. Topical antimicrobial dressings may be beneficial when wounds are chronically or heavily colonised1 (II)

13. The ulcer should be irrigated with a neutral, non-irritating solution, e.g. warmed sterile water or saline, and cleansed with minimal chemical or mechanical trauma1 (IV)

14. Removal of necrotic and devitalised tissue should be undertaken through mechanical, sharp, autolytic or biological debridement, unless revascularisation is necessary1,7 (II)Sharp debridement should only be undertaken by health professionals with experience and training in the area5 (EO)

15. Dressings should: - maintain a moist wound-healing environment (except where dry gangrene or eschar is present)1 (III)

- manage wound exudate and protect peri-ulcer skin1 ( I )

16. Treatment should be re-evaluated when there is failure to achieve ulcer size reduction of 40% after 4 weeks of therapy1 (II)

17. Optimising glucose control improves wound healing1 (III)

18. In some clients, additional therapy may be helpful, as follows:

- topical negative pressure wound therapy promotes healing of diabetic wounds3,4 (II)

- cultured skin equivalents may be of benefit in healing diabetic foot ulcers3 (I)

- hyperbaric oxygen therapy reduces risk of amputation in patients with ischemic diabetic foot ulcers3 (I)

Prevention

19. Offer a foot protection program for people who are assessed as having intermediate or high risk for foot ulceration, including foot care education, podiatry review and appropriate footwear3 (II)

20. Protective footwear should be prescribed for all at risk clients, i.e. those with PAD, neuropathy, previous foot ulceration and/or amputation, callus, foot deformity1 (II)

21. Acceptable methods of offloading include crutches, walkers, wheelchairs, custom shoes or inserts, shoe modifications, custom relief orthotic walkers, diabetic boots, forefoot and heel relief shoes, total contact casts1 (I)

22. Good foot care and daily inspection of the feet will reduce recurrence of foot ulceration1 (II)

23. A foot examination should be undertaken by a health professional with skills in the area:

- annually in people with low risk feet2,7 ( I ) - at least every 3-6 months in people with intermediate-risk or high risk feet3 (EO)

24. Glucose levels should be monitored regularly1,2 (II)

25. Potential modifiable risk factors for diabetic foot ulceration include peripheral vascular disease, neuropathy, foot deformities, plantar callus and smoking7 (IV)


Pressure Injuries








1. Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Osborne Park, WA: Cambridge Media 2012. http://www.awma.com.au/publications/2012_AWMA_Pan_Pacific_Guidelines.pdf

2. Association for the Advancement of Wound Care. Association for the Advancement of Wound Care guideline of pressure ulcer guidelines. Malvern, PA: AAWC 2010. http://www.guidelines.gov/content.aspx?id=24361

3. Stechmiller J et al. Guidelines for the prevention of pressure ulcers. Wound Repair and Regeneration 2008. 16: 151-168. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2008.00356.x/pdf

4. Wound Ostomy and Continence Nurses Society. Guideline for prevention and management of pressure ulcers. Mount Laurel, NJ: WOCN 2010. http://guideline.gov/content.aspx?id=23868

5. Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. (Revised). Toronto, ON: RNAO 2011. http://rnao.ca/sites/rnao-ca/files/Risk_Assessment_and_Prevention_of_Pressure_Ulcers.pdf

6. National Institute for Clinical Excellence. The use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. London: Royal College of Nursing 2004. http://www.ncbi.nlm.nih.gov/books/NBK48950/pdf/TOC.pdf

7. Royal College of Nursing. The management of pressure ulcers in primary and secondary care: A clinical practice guideline. London: RCN &NICE 2005. http://www.rcn.org.uk/__data/assets/pdf_file/0017/65015/management_pressure_ulcers.pdf

8. Hadwen G. Pressure area care: Prevention. (JBI) Best Practice: 2011. http://connect.jbiconnectplus.org

9. Whitney J et al. Guidelines for the treatment of pressure ulcers. Wound Repair and Regeneration 2006. 14: 663-679. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2006.00175.x/pdf

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Pressure Injuries [2 of 4]

Assessment1. All clients should be assessed for their

risk of developing pressure injuries on admission and following any change in health status.1, 2 The resulting risk status and risk factors should be documented regularly.3 Include a skin assessment1; (III)medical/surgical history1; (EO)and a pressure injury risk assessment tool.1, 2, 4, 5 (III)There is little evidence supporting the effectiveness of any one risk assessment tool over another1 (II)

2. Assessment should be carried out by staff with training and expertise in the assessment of risk factors and pressure injuries3, 6 (III)

3. Risk factors include: - Immobility or reduced physical mobility3, 6, 7 (III)

- Loss of sensation3, 6 (III) - Impaired cognitive state or level of consciousness6 (III)

- Urinary or faecal incontinence3 (III) - Poor nutrition or recent weight loss3, 6, 7 (III)

- Dry skin7 (III) - Acute or severe illness3, 6 (III)

4. Individuals found to be at risk of developing pressure injuries should have their skin assessed daily for signs of impaired skin integrity1, 8 (III)

5. Regularly assess and monitor wound characteristics (i.e. location, dimensions, stage, exudate characteristics, signs of infection, wound bed characteristics, surrounding skin, undermining or tracking, odour), and progress in healing, including use of a validated pressure injury healing assessment scale1 (III)

6. All clients with pressure injuries should be regularly assessed for presence of pain1, 5 (IV)using a validated pain assessment tool1, 5 (III)and a pain management plan developed1 (EO)

Management

7. The pressure injury stage should be documented using an accepted classification system, e.g. the NPUAP/EPUAP 2009 pressure injury classification system1 (EO)

8. Pressure-relieving surfaces and strategies (e.g. mobilising, regular repositioning) should be in place 24 hours/day for all individuals with pressure injuries6, 7, 9 (IV)

9. A high specification reactive (constant low pressure) or active (alternating pressure) support surface should be used in clients with pressure injuries1 ( I )

10. If there is no progress in healing, or a stage 3 – 4 injury is present (or unstageable or deep tissue injuries), an alternating pressure, low-air-loss, continuous low pressure system or air-fluidised bed should be used7, 9 ( I )

11. A static support surface may be appropriate for clients who can move freely and where there is no ‘bottoming out’2, 9; ( I )for clients who cannot move freely, or who ‘bottom out’, a dynamic support surface may be appropriate9 ( I )

12. Avoid positioning individuals directly on pressure injuries or bony prominences1 (III)


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13. Limit the amount of time with the head of bed elevated3, 9 (III)

14. The injury should be irrigated with a neutral, non-irritating, non-toxic solution, and cleansing undertaken with minimal chemical or mechanical trauma9 (IV)

15. Removal of necrotic and devitalised tissue should be undertaken through mechanical, sharp, autolytic or biological debridement9 (II)

16. Dressings should: - Maintain a moist wound-healing environment1, 9 ( I )

- Manage wound exudate and protect peri-ulcer skin1, 9 ( I )

- Remain in place and minimise shear, friction, skin irritation and pressure9 (II)

17. There is insufficient evidence to indicate:

- Whether any specific dressing is more effective in healing pressure injuries1 ( I )

- Whether antimicrobials are effective in treating pressure injuries7 ( I )

However, hydrocolloid dressings are generally more cost-effective than moist gauze1 (III)

18. The following interventions may promote healing in pressure injuries when used in combination with regular care:

- Topical negative pressure therapy, in stage 3-4 pressure injuries1 (III)

- Electrotherapy, in stage 2-4 injuries1 (II) - Pulsed electromagnetic therapy, in stage 2-4 injuries1 (III)

- Ultraviolet light C therapy, in stage 2-4 injuries1 (IV)

19. There is currently insufficient evidence to recommend:

- Hyperbaric oxygen therapy1 ( I ) - Infrared therapy1 (EO) - Laser therapy1 (EO) - Therapeutic ultrasound therapy1 ( I )

20. Provide high protein oral nutritional supplements in addition to a regular diet for clients with a pressure injury, including arginine supplements in people with a stage 2 or greater pressure injury1 (II)

Prevention

21. Formal documented policies and procedures should be in place to guide prevention plans for pressure injuries, including identification of areas and groups at risk3 (III)

22. Individuals found to be at risk of developing pressure injuries should have a preventative management plan in place1 (II)

23. A multidisciplinary team of health care professionals should evaluate preventative pressure injury care strategies at least quarterly3 (III)

24. High specification reactive support foam mattresses should be used rather than standard mattresses in individuals found as being at risk of developing a pressure injury.1 Active support mattresses could be used as an alternative in these clients1 ( I )

25. Heels should be completely off loaded in all positions for at-risk individuals5 (IV)

26. Avoid positioning individuals directly on bony prominences1 (EO)


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27. Pillows and foam wedges can be used to reduce pressure on bony prominences3 (II)

28. Avoid foam rings, donuts, or fluid filled bags for pressure reduction1, 3, 9 (II)

29. Avoid ordinary sheepskin - medical grade sheepskin is recommended 1 ( I )

30. Avoid prolonged sitting in a chair or wheelchair;1, 2 (II) and positioning hips at an angle greater than 90o when seated1 (EO)

31. Reposition the client as frequently as required. Frequency of repositioning should consider their risk, skin response, mobility, medical condition, and the support surface used1 (II)

32. Limit the amount of time with the head of bed elevated3 (III)and maintain head of bed at/or below 30˚ or at the lowest degree of elevation2, 4 (IV)

33. Employ correct lifting and manual handling techniques, including use of lift sheets or devices to transfer clients1, 3 (IV)

34. Protect skin exposed to friction1 (EO)

35. Avoid: - Potentially irritating substances on skin or substances that alter skin pH1, 3 (III)

- Dryness or maceration of skin (i.e. moisturise dry skin, avoid sustained contact with body fluids, encourage continence)1, 5 (IV)

- Vigorous massage over bony prominences2 (III)

36. Maintain optimal nutritional status;1, 2 (II)nutritional support should be given to those who are undernourished or with an identified nutritional deficiency7, 9 (IV)

37. Educate client/caregiver about the causes and risk factors for pressure injuries development and ways to minimise risk2, 4 (III)


Wound Care








1. World Union of Wound Healing Societies. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd 2004. www.woundsinternational.com/pdf/content_39.pdf

2. Australian Wound Management Association. Standards for wound management. 2nd ed. Osborne Park, WA: Cambridge Media 2010. www.awma.com.au/publications/2011_standards_for_wound_management_v2.pdf

3. The Wound Healing and Management Node Group. Chronic wound management. (JBI) Best Practice: 2011. http://connect.jbiconnectplus.org

4. Australian Wound Management Association. Position Document: Bacterial impact on wound healing: From contamination to infection. AWMA 2011. www.awma.com.au/publications/2011_bacterial_impact_position_1.5.pdf

5. Hopf H et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair and Regeneration 2006. 14(6): 693-710. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2006.00177.x/pdf

6. World Union of Wound Healing Societies. Principles of best practice: Wound exudate and the role of dressings. A consensus document. London: MEP Ltd 2007. www.woundsinternational.com/pdf/content_42.pdf

7. Medical Advisory Secretariat. Community-based care for chronic wound management: An evidence-based analysis. Ontario Health Technology Assessment Series 2009. 9(18). www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_smcc_wound_20091019.pdf

8. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database of Systematic Reviews 2012(2). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003861.pub3/pdf

9. Whitney J et al. Guidelines for the treatment of pressure ulcers. Wound Repair and Regeneration 2006. 14(6): 663-679. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2006.00175.x/pdf

10. Best Practice Statement: The use of topical antiseptic/antimicrobial agents in wound management. 2nd ed. Wounds UK 2011. www.wounds-uk.com/best-practice-statements

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These guidelines have been developed for health professionals caring for clients with wounds. Assessment and management of wounds should be undertaken by health professionals with expertise in the area.


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Wound Care [2 of 3]

Assessment

1. Assessment and wound management should be carried out by staff with training, skills and experience in wound care1 (EO)

2. Assess and document: physical examination, medical history, social history, psychological well-being, nutritional status, pain (include a pain scale), history of previous wounds, current wound duration, site, current and previous wound treatments2 (EO)

3. Assess, classify and document wound size, shape, depth, tissue type, colour, odour, exudate, wound margin, surrounding skin and tissue condition2 (EO)

4. Assess and document signs of infection: cellulitis, erythema, malodour, increased pain, delayed healing, deterioration of the wound, purulent exudate2 (IV)

5. Reassess and document progress in healing regularly 3, including evaluation of the response of the client and wound to any treatment for wound infection4

6. Ongoing assessment of pain should be performed before, during, and after each dressing procedure;1 (EO)

using a standardized assessment tool1 (IV)

7. Referral for specialist treatment may be necessary if there is:

- failure to progress to heal - unexpected change in level or type of exudate

- unexpected change in level or type of pain

- there is uncertainty in diagnosis - signs of infection - the ulcer appears ischemic1,5,6 (EO)

Management

8. Managing chronic wounds with a multidisciplinary team promotes wound healing and reduces severity of wound-associated pain and frequency of wound treatments7 (III)

9. Strategies for minimising infection risk should be embedded in a wound management plan4 (EO)

10. Acute and chronic wounds may be cleansed using potable tap water if normal saline is unavailable8 ( I )

11. The ulcer should be irrigated with a neutral, non-irritating, non-toxic solution, and cleansing undertaken with minimal chemical or mechanical trauma9 (IV)

12. Removal of necrotic and devitalised tissue should be undertaken through mechanical, sharp, autolytic or biological debridement9 (II)

* If dry gangrene or eschar is present, however, debridement should not be undertaken until arterial flow has been re-established5 (III)

13. A moist wound environment should be maintained for optimal healing2 (IV)A moist wound environment promotes healing by enabling migration of tissue-repairing cells and spread of immune and growth factors. Extreme wetness or dryness may delay healing6 (IV)


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Wound Care [3 of 3]

14. Dressings should: - maintain a moist wound-healing environment2,3 (IV)

- manage wound exudate and protect peri-ulcer skin6 ( I )

- remain in place and minimise shear, friction, skin irritation and pressure9 (II)

- be non-adherent to reduce trauma on removal1,6 (EO)

- however, dry gangrene or eschar is best left dry until revascularisation5 (III)

15. Dressings should be cost effective, acceptable to the client and able to be changed once per day or less often when possible1,6 (II)

16. A topical antimicrobial agent should be used in clients with critically colonised, localised or spreading wound infection;4 (III)the length of treatment should be determined by the response of the wound and the client4 (EO)

17. Adequate oxygenation of the wound environment will promote healing, and should be promoted through avoidance of dehydration, cold, stress and pain5 (III)

18. Effective pain management strategies should be implemented to minimise pain during wound dressing procedures1 (EO)

19. Maintain optimal levels of nutrition3 (II)

20. Provide client education on all aspects of wound management6 (EO)

21. Promote psychosocial support6 (EO)










1. Australian Wound Management Association, Standards for wound management. 2nd ed 2010, Osborne Park, WA: Cambridge Media. www.awma.com.au/publications/2011_standards_for_wound_management_v2.pdf

2. Trans Tasman Dietetic Wound Care Group, Evidence based practice guidelines for the dietetic management of adults with pressure injuries. Review 1: 2011. http://daa.asn.au/wp-content/uploads/2011/09/Trans-Tasman_Dietetic-Wound-Care-Group-Pressure-Injury-Guidelines-2011.pdf

3. Dorner B, Posthauer M, Thomas D, National Pressure Ulcer Advisory Panel, The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel White Paper 2009. www.ncbi.nlm.nih.gov/pubmed/19521288

4. Australian Wound Management Association, Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury 2012, Osborne Park, WA: Cambridge Media www.awma.com.au/publications/2012_AWMA_Pan_Pacific_Guidelines.pdf

5. Wilkinson E: Oral zinc for arterial and venous leg ulcers. Cochrane Database of Systematic Reviews 2012. Issue 8, CD001273.

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This summary has been developed for health professionals caring for clients with impaired skin integrity or those at risk of loss of skin integrity. Assessment and management of skin integrity should be undertaken by health professionals with expertise in the area.


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Nutrition and Wound Healing [2 of 2]

Assessment

1. Nutritional screening and assessment should be conducted in people with or at risk of developing a wound in all health care settings,1,2 (EO)using a validated tool, such as the Mini Nutritional Assessment (MNA)2 (III)

2. Nutritional assessment is a continual monitoring and review process which lasts as long as the wound healing process, with each condition change and/or delayed healing2,3 (EO)

3. Document nutritional status of people with, or at risk of, developing a wound1 (EO)

Management

4. Address nutritional deficits to optimise the wound healing potential of the individual1 (EO)

5. Nutritional interventions should be implemented to assist healing of pressure injuries2 (III)Start with modification of current dietary intake, and progress to the use of oral nutritional supplements when adequate intake of nutrients is not provided from dietary sources2 (III)

6. Consider the following oral nutritional supplements for wound healing

- A high protein supplement in people with a pressure injury4 (II)

- Arginine containing supplements in people with a stage 2 or greater pressure injuries and without infection or sepsis2,4 (II)

- Multivitamin supplements in people with a pressure injury who are identified as having nutritional deficits4 (II)

7. Oral zinc supplements do not improve healing of arterial and venous leg ulcers5 (II)

Prevention

8. Maintain optimal nutritional status with adequate calories, protein, carbohydrates, fat and vitamins and minerals2,3 (II)

9. A high protein oral nutritional supplement together with a regular diet may help prevent development of pressure injuries in people at a high risk of pressure injury4 (II)

10. Refer people with nutritional risks or deficits to a dietician2 (EO)



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Nutrition & Hydration


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✔Drink plenty of fluids (fluids can include water, jelly, soup, juice, ice-cream)

Have a variety of healthy snacks handy

Eat a balanced, healthy diet with adequate calories and protein

Sit upright when eating or drinking

Ensure good dental hygiene

Nutrients important for wound healing include:

– Protein (1–2 serves per day, e.g. meat, dairy products, legumes, nuts)

– Vitamin C (2–5 serves per day, e.g. citrus fruits, berries, capsicum, kiwi fruit, broccoli)

– Vitamin A (1-2 serves per day, e.g. sweet potato, carrots, broccoli, spinach, rockmelon)

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Compression Stockings


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✔Replace compression stockings every 6 months or if they have a ladder or hole

Remove compression stockings immediately and seek advice if toes go purple or blue, the leg swells above or below the stockings, or you develop severe pain

If you remove compression stockings at night, reapply them first thing in the morning

Use a stocking applicator

Gently hand wash stockings, squeeze moisture out in a towel and dry in the shade

Wear rubber dishwashing gloves to help put your stockings on and to remove your stockings more easily

✘Do not wear rings, watches and jewellery when applying compression stockings

Do not leave any wrinkles in compression stockings

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Wound Care


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✔Clean wounds gently with clean tap water or saline – avoid strong chemicals

Keep wounds moist by covering them with a dressing

Reduce frequency of dressing changes to once per day or less often when possible

Avoid getting any non-waterproof wound dressings wet

Use a non-adherent wound dressing - if it sticks, soak off with tap water or saline

See your health professional if increased heat, redness, swelling or purulent discharge occurs

✘Do not leave a wound open to the air or sun – dry wounds heal more slowly

Do not use tape or adhesives on your skin

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Pressure Injuries


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✔Change position frequently

Use a high specification mattress if at risk of pressure injuries

Use pillows and foam wedges to protect bony areas

Use an unscented, soap-free body wash

Eat a healthy nutritious diet

✘Do not use foam rings or donuts

Avoid rubbing or massaging over bony areas

Avoid any contact of heels or sacrum with hard surfaces

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✔Have a podiatrist care for and check your feet at least once a year

Inspect, wash and dry feet daily, especially between toes

Monitor blood sugar levels regularly

Check shoes and socks for sharp or rough edges or seams before putting them on

Check the temperature of the water before putting your feet in

✘Do not walk indoors or outdoors without well-fitting shoes

Do not smoke

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Arterial Leg Ulcers


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✔Exercise legs gently and often – try walking or ankle exercises (flexing, circling)

Have a podiatrist care for your feet

Protect your legs and feet – wear shoes that fit well and orthotics if needed

Keep legs warm – e.g. rugs, clothes – do not use a heat source near/on them

Keep yourself at a healthy weight

Control diabetes, lipids and blood pressure

✘Do not smoke

Never put compression bandages or stockings on a leg with poor arterial supply

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Venous Leg Ulcers


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✔Wear compression stockings or socks. A stocking applicator can help put them on

Have your compression stockings fitted professionally

Replace stockings every six months or if damaged

Put your feet up (higher than your heart) 3-4 times each day for at least 15 minutes

Exercise regularly e.g. walking or ankle exercises

Moisturise your skin twice daily

Check your legs daily for any broken areas, swelling or redness, and see your health professional for regular check-ups

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Skin Tears


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✔Moisturise skin twice daily

Pad or cushion equipment and furniture (e.g. walkers, wheelchairs)

Drink 6-8 glasses of fluid every day

Wear long sleeves and pants, or limb protectors to protect the skin

Ensure adequate lighting to avoid bumping into furniture

✘Do not use soap – use an unscented, soap-free body wash to avoid drying the skin

Avoid tapes and adhesives on the skin

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Skin Care


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✔Use unscented, soap-free body wash

Moisturise skin twice daily – apply in the direction of hair growth

Pat skin dry, do not rub

Protect skin exposed to friction

Eat a healthy balanced diet and drink 6-8 glasses of fluid every day

✘Avoid overheating skin – change position regularly

Avoid leaving skin in contact with moisture – barrier creams may help


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3.2.2 Tip sheetsIt has been found that clients, family and carers appreciate a simple list of dos and don’ts to manage and prevent wounds. The tipsheets provide wound sufferers and their carers with such a list. Tip sheets in conjunction with the relevant brochures are a valuable resource for CSIs to distribute to clients, family and carers.

• Skin Care

• Skin Tears





• Wound Care

• Compression Stockings

• Nutrition and Hydration

The following print resources can be photocopied directly from this booklet or alternatively can be printed from the relevant files included on the CSI resource files CD. Two different files of each print resource is available on the CD. The ones with LocalPrinter included in the filespec can be printed to the local printer connected to your PC. The ones with CommercialPrinter included in the filespec can be sent to a commercial printer for a professional output.

Samples of all the tip sheets are included at the back of this booklet

3

Skin Care


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✔Use unscented, soap-free body wash

Moisturise skin twice daily – apply in the direction of hair growth

Pat skin dry, do not rub

Protect skin exposed to friction

Eat a healthy balanced diet and drink 6-8 glasses of fluid every day

✘Avoid overheating skin – change position regularly

Avoid leaving skin in contact with moisture – barrier creams may help


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References:

Best Practice Statement: Care of the Older Person’s Skin. 2nd ed. 2012: Wounds UK.

The Joanna Briggs Institute: Topical skin care in aged care facilities. Best Practice: 2007, 11:1-4

AWMA, Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury 2012, Cambridge Media Osborne Park, WA.

Stechmiller J et al.: Guidelines for the prevention of pressure ulcers. Wound Rep Regen 2008, 16:151-68


60 Musk Ave Kelvin Grove Qld 4059 Brisbane, Australia

Email: [email protected] Email (Wound Healing): [email protected]

www.ihbi.qut.edu.auCRICOS No. 00213J


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Skin Tears


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✔Moisturise skin twice daily

Pad or cushion equipment and furniture (e.g. walkers, wheelchairs)

Drink 6-8 glasses of fluid every day

Wear long sleeves and pants, or limb protectors to protect the skin

Ensure adequate lighting to avoid bumping into furniture

✘Do not use soap – use an unscented, soap-free body wash to avoid drying the skin


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References:

Ayello E, Sibbald R, Preventing pressure ulcers and skin tears, in Evidence-based geriatric nursing protocols, Capezuti et al. Eds. 2008, Springer: New York. 403-29

Ratliff C, Fletcher K, Skin Tears: A review of the evidence to support prevention and treatment. Ostomy Wound Management, 2007.53(3)

Best Practice Statement: Care of the Older Person’s Skin. Wounds UK, 2012, 2nd ed





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Venous Leg Ulcers


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✔Wear compression stockings or socks. A stocking applicator can help put them on

Have your compression stockings fitted professionally

Replace stockings every six months or if damaged

Put your feet up (higher than your heart) 3-4 times each day for at least 15 minutes

Exercise regularly e.g. walking or ankle exercises

Moisturise your skin twice daily

Check your legs daily for any broken areas, swelling or redness, and see your health professional for regular check-ups

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References:

RNAO, Assessment and Management of Venous Leg Ulcers, 2004, RNA0: Toronto

AWMA, Australian and New Zealand Clinical Practice Guidelines for Prevention and Management of Venous Leg Ulcers, 2011, AWMA: Barton.ACT

SIGN, Management of chronic venous leg ulcers, 2010, SIGN: Edinburgh





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Arterial Leg Ulcers


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✔Exercise legs gently and often – try walking or ankle exercises (flexing, circling)

Have a podiatrist care for your feet

Protect your legs and feet – wear shoes that fit well and orthotics if needed

Keep legs warm – e.g. rugs, clothes – do not use a heat source near/on them

Keep yourself at a healthy weight

Control diabetes, lipids and blood pressure

✘Do not smoke

Never put compression bandages or stockings on a leg with poor arterial supply

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References:

Scottish Intercollegiate Guidelines Network, Diagnosis and management of peripheral arterial disease. 2006, Edinburgh: SIGN

Hopf H et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Rep Regen 2006. 14:693

National Clinical Guideline Centre, Lower limb peripheral arterial disease. NICE Guideline 147, 2012: London

Hopf H et al. Guidelines for prevention of lower extremity arterial ulcers. Wound Rep Regen 2008. 16:175





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✔Have a podiatrist care for and check your feet at least once a year

Inspect, wash and dry feet daily, especially between toes

Monitor blood sugar levels regularly

Check shoes and socks for sharp or rough edges or seams before putting them on

Check the temperature of the water before putting your feet in

✘Do not walk indoors or outdoors without well-fitting shoes

Do not smoke

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References:

Steed DL et al. Guidelines for the treatment of diabetic ulcers. Wound Repair and Regeneration 2006. 14(6):680-692

Steed DL et al. Guidelines for the prevention of diabetic ulcers. Wound Repair and Regeneration 2008. 16(2):169-174

National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes. Melbourne Australia 2011

McIntosh A et al. Prevention and Management of Foot Problems in Type 2 Diabetes. Sheffield: NICE 2003





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Pressure Injuries


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✔Change position frequently

Use a high specification mattress if at risk of pressure injuries

Use pillows and foam wedges to protect bony areas

Use an unscented, soap-free body wash

Eat a healthy nutritious diet

✘Do not use foam rings or donuts

Avoid rubbing or massaging over bony areas

Avoid any contact of heels or sacrum with hard surfaces

TIP

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References:

AWMA. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Osborne Park, WA: Cambridge Media 2012

AAWC. Association for the Advancement of Wound Care guideline of pressure ulcer guidelines. Malvern, PA: AAWC 2010

Stechmiller J et al. Guidelines for the prevention of pressure ulcers. Wound Rep Regen 2008. 16:151-168

RNAO. Risk assessment and prevention of pressure ulcers. (Revised). Toronto, ON: RNAO 2011


Wound Care


promoting

✔Clean wounds gently with clean tap water or saline – avoid strong chemicals

Keep wounds moist by covering them with a dressing

Reduce frequency of dressing changes to once per day or less often when possible

Avoid getting any non-waterproof wound dressings wet

Use a non-adherent wound dressing - if it sticks, soak off with tap water or saline

See your health professional if increased heat, redness, swelling or purulent discharge occurs

✘Do not leave a wound open to the air or sun – dry wounds heal more slowly

Do not use tape or adhesives on your skin

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References:

AWMA. Standards for wound management. 2nd ed. Osborne Park, WA: Cambridge Media 2010

WUWHS. Principles of best practice: Wound exudate and the role of dressings. London: MEP Ltd 2007

Fernandez R and Griffiths R. Water for wound cleansing. Cochrane Database of Systematic Reviews 2012(2)

Whitney J et al. Guidelines for the treatment of pressure ulcers. Wound Rep Regen 2006.14:663-79





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Compression Stockings


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✔Replace compression stockings every 6 months or if they have a ladder or hole

Remove compression stockings immediately and seek advice if toes go purple or blue, the leg swells above or below the stockings, or you develop severe pain

If you remove compression stockings at night, reapply them first thing in the morning

Use a stocking applicator

Gently hand wash stockings, squeeze moisture out in a towel and dry in the shade

Wear rubber dishwashing gloves to help put your stockings on and to remove your stockings more easily

✘Do not wear rings, watches and jewellery when applying compression stockings

Do not leave any wrinkles in compression stockings

TIP

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References:

RNAO, Assessment and Management of Venous Leg Ulcers, 2004, RNA0: Toronto

AWMA, Australian and New Zealand Clinical Practice Guidelines for Prevention and Management of Venous Leg Ulcers, 2011, AWMA: Barton. ACT

SIGN, Management of chronic venous leg ulcers, 2010, SIGN: Edinburgh





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Nutrition & Hydration


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✔Drink plenty of fluids (fluids can include water, jelly, soup, juice, ice-cream)

Have a variety of healthy snacks handy

Eat a balanced, healthy diet with adequate calories and protein

Sit upright when eating or drinking

Ensure good dental hygiene

Nutrients important for wound healing include:

– Protein (1–2 serves per day, e.g. meat, dairy products, legumes, nuts)

– Vitamin C (2–5 serves per day, e.g. citrus fruits, berries, capsicum, kiwi fruit, broccoli)

– Vitamin A (1-2 serves per day, e.g. sweet potato, carrots, broccoli, spinach, rockmelon)

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References:

Trans Tasman Dietetic Wound Care Group, Evidence based practice guideline for the dietetic management of adults with pressure injuries. Review 1: 2011

Dorner B et al, The role of nutrition in pressure ulcer prevention and treatment, 2009, NPUAP

AWMA, Pan Pacific Clinical Practice Guideline for Prevention and Management of Pressure Injury 2012, Osborne Park, WA: Cambridge Media

Australian Government NHMRC, Dietary Guidelines for Australian Adults, www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n29.pdf





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Pressure Injury Flow Chart

Pressure ulcer classification system*

References:AWMA. Pan Pacific Clinical Practice Guideline for Prevention and Management of Pressure Injury. Osborne Park, WA: Cambridge Media 2012 • AAWC. AAWC guideline of pressure ulcer guidelines. Malvern, PA: AAWC 2010 • Stechmiller et al. Guidelines for prevention of pressure ulcers. Wound Rep Regen 2008. 16:151-168 • WOCN. Guideline for prevention and management of pressure ulcers. Mount Laurel NJ:WOCN 2010 • RNAO. Risk assessment and prevention of pressure ulcers. (Revised). Toronto, ON: RNAO 2011 • NICE. The use of pressure-relieving devices for the prevention of pressure ulcers. London: RCN 2004 • Royal College of Nursing. Management of pressure ulcers. London: RCN and NICE 2005 • Whitney et al. Guidelines for treatment of pressure ulcers. Wound Rep Regen 2006. 14:663-79

• Undertake a pressure injury risk assessment (e.g. Waterlow, Braden)

- on admission - at regular intervals - upon a change in health status

• If a client is found to be ‘at risk’, assess skin at least daily

• Suspected stage 1 pressure injuries should be reassessed 20 minutes after pressure is relieved

• Regularly assess for pain and develop a pain management plan if appropriate

Reduced physical mobility

Loss of sensation

Impaired cognition or level of consciousness

Incontinence

Poor nutrition or recent weight loss

Dry skin or skin in constant contact with moisture

Acute or severe illness

• Irrigate with warm clean water or normal saline

• Clean the wound gently

• Remove necrotic or devitalised tissue*

*Mechanical or sharp debridement should only be done by trained clinicians

• Select a dressing which will: - maintain a moist wound bed - manage wound exudate - protect the surrounding skin - minimise shear, friction & pressure - topical negative pressure may benefit stage III & IV ulcers

• Use a high specification reactive or active support surface for clients with pressure injuries

• Stage III, IV, unstageable or deep tissue injuries require an alternating pressure, low air-loss, continuous low pressure system, or air-fluidized bed; close observation; and a repositioning regime

• Avoid positioning directly on bony prominences or pressure injuries

• Avoid shear and friction

• Limit the amount of time the head of bed is elevated

• Use pillows and foam wedges to elevate or reposition bony prominences e.g. heels, hips

• Provide high protein nutritional supplements, including arginine, for those with a stage 2 or greater pressure injury

• A multidisciplinary approach is needed, include physiotherapy, occupational therapy, nursing, dietitian and medical practitioner

Level of risk and risk factors present

Prevention strategies

Wound assessment and management (size, stage, location, tissue, exudate, surrounding skin, interventions)

Progress and outcome of interventions, including use of a validated healing scale

Risk factors for a Pressure Injury Document


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Unstageable/Unclassified

Suspected deep tissue injury.

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar. Staging cannot be determined until slough and/or eschar are removed.

Suspected deep tissue inury

Purple or maroon localised area of discoloured intact skin or blood- filled blister, due to damage of underlying tissue from pressure and/or shear. The area maybe preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Stage IV Full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Depth varies by anatomical location.

Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling. Depth varies according to anatomical location.

Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed. May also present as an intact or open/ruptured serum-filled blister The blister is shiny or a dry shallow ulcer without slough or bruising (if bruising is present in the blister it indicates deep tissue injury).

Stage I Intact skin with non-blanchable redness of a localized area, usually over a bony prominence.

The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.

Assessment Wound Bed Management Management Prevention

• Individuals found at risk should have a preventive plan in place

• Provide a high-specification foam or active support mattress for at risk clients

• Off-load heels for at risk clients

• Avoid positioning directly on bony prominences

• Reposition as frequently as required, considering response, condition and support surface

• Avoid foam rings, donuts or fluid filled bags

• Limit the amount of time with head of bed elevated

• Avoid potentially irritating substances on the skin

• Avoid maceration of skin – use barrier preparations or creams

• Maintain optimal nutritional status

Symptoms of pressure damage

Localised heat, oedema, redness

Skin feels firm or boggy to touch

Darkly pigmented skin may be maroon or purple rather than red

This project is funded by the Australian Government Department of Health and Ageing under the Encouraging Better Practice in Aged Care (EBPAC) programReference NPUAP 2007 http:/www.npvap.org/resources.htm

Diabetic Foot Ulcer Flow Chart


promoting



Diabetic ulcers typically:

Occur on the sole of the foot or over pressure points e.g. toes

The wound bed can be shallow or deep, producing low to moderate amounts of exudate

The surrounding skin is usually dry, thin and frequently has callous formation

• Reduce pressure – offload pressure points e.g. use crutches, wheelchairs, custom shoes or inserts, orthotic walkers, diabetic boots, or total contact casts

• Promote oxygenation of the wound by avoiding dehydration, smoking, cold, stress and pain

• Optimise glucose control

• Regularly document progress in healing

• Re-evaluate treatment if failure to achieve 40% ulcer size reduction after 4 weeks

• A multidisciplinary team is needed; include podiatrists, orthotists, dietitians, GPs, wound care nurses and endocrinologists

• Consult remote expert advice with digital imaging for clients living in remote areas

• Assess all clients with diabetes for PAD, neuropathy and foot deformity and classify the level of risk

• Protective footwear is required for those at risk, i.e. with PAD, neuropathy, callus, foot deformity and/or previous ulceration

• Offload pressure points as detailed under ‘Management’

• Practise good foot care and daily inspection of feet

• Ensure an annual foot examination by a health professional (3 – 6 monthly if at moderate or high risk)

• Monitor and optimise blood glucose levels

• Quit smoking

Characteristics of a Diabetic Foot Ulcer

Uncertainty of diagnosis

There is a low or high ABPI

Symptoms impact on quality of life

Complicated ulcers e.g. multiple aetiology

Signs of infection or wound probes to bone

No progress in healing or deterioration of ulcer

When to Refer

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History

• Medical • Medications • Wound • Psychosocial / activities of daily living

Characteristics of the wound

• Use a validated classification tool

Inspect for foot deformities

Diagnostic investigations*

• Screen all clients for peripheral arterial disease (PAD), including an ankle brachial pressure (ABPI)

• An ABPI less than 0.9 indicates arterial disease

• ABPI greater than 1.2 indicates a need for further investigation

• Use monofilament testing to assess for loss of sensation and neuropathy

* Assessment should only be undertaken by a trained health professional

• Cleanse the wound with a neutral, non-irritating solution e.g. warm water or normal saline

• Cleanse wound bed gently to avoid trauma

• Remove necrotic or devitalised tissue, unless revascularisation is needed*

* Mechanical or sharp debridement should only be done by a trained health professional

• Select a dressing which will: - maintain a moist wound environment (except where dry gangrene or eschar is present)

- protect the surrounding skin - manage wound exudate - topical antimicrobial dressings will help chronically or heavily colonised wounds

References:Steed DL et al. Guidelines for the treatment of diabetic ulcers. Wound Rep Regen 2006. 14(6):680-692 • Steed DL et al. Guidelines for the prevention of diabetic ulcers. Wound Rep Regen 2008. 16(2):169-174 • National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes. Melbourne Australia 2011 • Scottish Intercollegiate Guidelines Network Management of diabetes. Edinburgh: SIGN 2010 • RNAO Assessment and Management of Foot Ulcers for People with Diabetes. Toronto: RNAO 2005 • McIntosh A et al. Prevention and Management of Foot Problems in Type 2 Diabetes. Sheffield: NICE 2003

Monofilament testing to check sensation

Arterial Leg Ulcer Flow Chart


promoting


References:Scottish Intercollegiate Guidelines Network, Diagnosis and management of peripheral arterial disease. 2006, Edinburgh: SIGN • Hopf H et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Rep Regen, 2006. 14(6):693-710 • National Clinical Guideline Centre, Lower limb peripheral arterial disease. Diagnosis and management. NICE Clinical Guideline 147, 2012: London • Hopf H et al. Guidelines for prevention of lower extremity arterial ulcers. Wound Rep Regen, 2008. 16(2):175-188 • RNAO, Assessment and management of foot ulcers for people with diabetes. 2005


History


Characteristics of the wound (see table below)

Diagnostic investigations

All patients with a leg ulcer should be screened for arterial disease, including an Ankle Brachial Pressure Index (ABPI)

* Assessment should only be undertaken by a trained health professional

Arterial leg ulcers typically:

• Occur on the anterior shin, ankle bones, heels or toes

• Have pain which is relieved when legs are lowered below the level of the heart

• Have ‘punched out’ wound edges

• May have mummified or dry and black toes

The surrounding skin or tissue often has:

• Shiny or dry skin

• Devitalised soft tissue with dry or wet crust

• Thickened toe nails

• A purplish colour when the leg is lowered to the ground

• Loss of hair

• Cool skin

• Cleanse the wound gently with warm water or normal saline. Pat dry.

• In general, debride necrotic or devitalised tissue: however, do not debride dry gangrene or eschar

* Debridement should be undertaken only by a trained health professional

• Maintain a moist wound environment, however, if dry gangrene or eschar is present, it is best left dry

• Topical antimicrobial dressings may be beneficial when wounds are chronically or heavily colonised

• Promote oxygenation through avoidance of:

- smoking - dehydration - cold - stress and pain

• Refer to vascular surgeon for restoration of blood flow by revascularisation, if appropriate

• Ensure optimal pain management strategies

• Reduce risk factors: - cease smoking - control diabetes mellitus - control elevated lipids - control hypertension - anti-platelet therapy - control weight

• Refer to vascular surgeon for assessment if appropriate

• Exercise the lower limbs

• Protect legs and feet: - ensure soft, conforming, proper fitting shoes

- refer to podiatrist for general footcare, orthodics and offloading as necessary

- protect legs (e.g. padded equipment, long clothing)

- use pressure relief devices e.g. high density foam or air cushion boots for those with limited mobility

• Keep the legs warm (e.g. socks, rugs)

• Eat a nutritious diet• uncertainty of diagnosis

• a low ABPI < 0.8 or a high ABPI > 1.2

• symptoms impact on quality of life

• multiple aetiology

• signs of infection

• ulcer appears ischaemic

• failure to heal

Characteristics of an Arterial Leg Ulcer When to Refer

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Venous Leg Ulcer Flow Chart


promoting


References:AWMA, Australian and New Zealand Clinical Practice Guidelines for Prevention and Management of Venous Leg Ulcers, 2011, AWMA: Barton.ACT • RCN, The management of patients with venous leg ulcers, 2006, RCN: London • RNAO, Assessment and Management of Venous Leg Ulcers, 2004,RNAO: Toronto • SIGN, Management of chronic leg ulcers, 2010, SIGN: Edinburgh


Venous leg ulcers typically

Occur on the lower third of the leg

Have pain usually relieved by elevation of the legs above heart level

Are shallow and have irregular, sloping wound margins

Produce moderate to heavy exudate

• Multilayered high compression therapy should be applied following diagnosis of an uncomplicated venous leg ulcer

* Compression therapy should only be applied by a trained practitioner

• Check ankle circumference measures more than 18cm

• Apply moisturiser to the lower limb

• Apply padding over bony prominences

• Apply compression system as per manufacturers’ guidelines

• Remove bandaging if there is: - slippage of bandage - decreased sensation of lower limb - toes go blue or purple, or leg swells above or below the bandage

- increased pain in the foot or calf muscle that is unrelieved by leg elevation for 30 minutes above heart level

- increased shortness of breath or difficulty breathing

• Monitor Progress: Trace wound before starting compression therapy, then every 2–4 weeks, or when rapid changes occur

• Use of compression stockings for life reduces leg ulcer recurrence (Class 3 (40mm Hg) if tolerated, or highest level tolerated)

* A trained practitioner should fit compression stockings

• Replace compression stockings every 6 months

• Provide education to clients and carers on compression stocking application and removal techniques

• Refer to vascular surgeon if appropriate

• Monitor regularly, every 3 months

• Apply moisturiser twice daily

• Elevate the affected limb above heart level daily

• Encourage ankle and calf muscle exercises

• Repeat Doppler ABPI every 3 months, or whenever changing the type of compression therapy

Characteristics of a Venous Leg Ulcer

When to Refer

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History


Characteristics of the wound (see table below)

Diagnostic investigations:

• All patients with a leg ulcer should be screened for arterial disease, including an Ankle Brachial Pressure Index (ABPI)*

• Reassess the ABPI every 3 months or if clinically indicated

* Compression therapy is contraindicated if the ABPI is <0.8 or >1.2

* Assessment should only be undertaken by a trained health practitioner

• Irrigate with warm water or normal saline. Pat dry

• Clean the wound gently (avoid mechanical trauma)

• Remove necrotic or devitalised tissue (e.g. autolytic debridement)*

• EMLA® cream can reduce pain associated with debridement

* Mechanical or sharp debridement should only be done by a trained practitioner

• Select a dressing that will: - maintain a moist wound bed - manage wound exudate - protect the surrounding skin

The surrounding skin often has:

Haemosiderin (brown) staining

Hyperkeratosis (dry, flaky skin)

Venous stasis eczema

Inverted champagne bottle leg appearance

Uncertainty in diagnosis

Complex ulcers (multiple aetiology)

ABPI <0.8 or >1.2

No reduction in wound size within 4 weeks after starting compression

Deterioration of ulcer

Signs of infection

Failure to improve after 3 months

3.2.3 Flow ChartsFlow charts have been designed to be mounted on notice boards in areas where wounds are managed. They provide the health professional caring for wounds with an easy to follow ready reference for the assessment, management and prevention of each of the major wound categories. It has been found that flow charts printed at A3 size and laminated provide an excellent wall mounted wound management tool.

• Skin Tear Management

• Venous Leg Ulcer

• Arterial Leg Ulcer

• Diabetic Foot Ulcer

• Pressure Injury


Skin Tear Management Flow Chart

Assessment

STAR classification system

Management Prevention

References:Ayello E, Sibbald R, Preventing pressure ulcers and skin tears, in Evidence-based geriatric nursing protocols for best practice, E Capezuti, et al., Eds. 2008, Springer: New York. • LeBlanc K, Baranoski S, Skin tears: Adv Skin Wound Care, 2011. 24(9S): 2-15 • Ratliff C, Fletcher K, Skin Tears: Ostomy Wound Management, 2007. 53(3) http://www.o-wm.com/article/6968 • Carville K et al., STAR: A consensus for skin tear classification. Primary Intention, 2007. 15(1): 18–28 • Joanna Briggs Institute, Topical skin care in aged care facilities. Best Practice, 2007. 11(3) • Wounds UK. Best Practice Statement: Care of the Older Person’s Skin Wounds UK 2012 , 2nd ed.


• All clients should have a risk assessment for skin tears on admission

• Assess and document skin tears using a recognised assessment and classification system e.g. STAR1

• Assess the surrounding skin for swelling, discolouration or bruising

If skin flap is pale, dusky or darkened:

• Reassess in 24-48 hours or at the first dressing change

* Assessment should only be undertaken by trained staff

1 Carville et al. 2007

History of previous skin tears

Bruising, discoloured, thin or

fragile skin

Cognitive impairment / dementia

Impaired sensory perception

Dependency

Multiple or high risk medications e.g. steroids, anticoagulants

Impaired mobility

Poor nutritional status

Dry skin / dehydration

Presence of friction, shearing and/or pressure

• Control bleeding

• Cleanse the wound gently with warm water or normal saline, pat dry

• Realign edges if possible - do not stretch the skin - use a moist cotton-tip to roll skin into place

• Apply a low adherent, soft-silicone dressing to wound, overlapping the wound by at least 2 cm

• Draw arrows on the dressing to indicate the direction of dressing removal

• Mark the date on the dressing

• Apply limb protector

• Assess skin regularly and implement a prevention protocol for those at risk

• Use soap-free bathing products

• Apply moisturiser twice daily

• Use correct lifting and positioning techniques

• Avoid wearing rings that may snag the skin

• When repositioning use assistive devices such as slide sheets

• Protect fragile skin with either limb protectors or long sleeves or pants

• Pad or cushion equipment and furniture

• Avoid using tapes or adhesives, use tubular retention bandages to secure dressings

Level of risk and risk factors present

Prevention strategies

Management strategies

Category of skin tear/s, size, location, tissue type, exudate, surrounding skin

Progress and outcome of interventions

Risk factors for a Skin Tear

Document


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Category 1aA skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is not pale, dusky or darkened.

Category 1bA skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is pale, dusky or darkened.

Category 2aA skin tear where the edges can not be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened.

Category 2bA skin tear where the edges can not be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened.

Category 3A skin tear where the skin flap is completely absent.

Skin Tear Audit Research (STAR). Silver Chain Nursing Association and School of Nursing and Midwifery, Curtin University of Technology. Revised 4/2/2010

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cers

, 200

6, R

CN

: Lon

don

• R

NA

O,

Ass

essm

ent a

nd M

anag

emen

t of V

enou

s Le

g U

lcer

s, 2

004,

RN

AO

: Tor

onto

•

SIG

N, M

anag

emen

t of c

hron

ic le

g ul

cers

, 201

0, S

IGN

: Edi

nbur

gh

This

pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of H

ealth

and

Age

ing

unde

r the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

Car

e (E

BPA

C) p

rogr

am

Venou

s le

g ulc

ers

typic

ally

Occ

ur o

n th

e lo

wer

third

of t

he le

g

Hav

e pa

in u

sual

ly re

lieve

d by

el

evat

ion

of th

e le

gs a

bove

hea

rt le

vel

Are

sha

llow

and

hav

e irr

egul

ar,

slop

ing

wou

nd m

argi

ns

Pro

duce

mod

erat

e to

hea

vy e

xuda

te

• M

ultil

ayer

ed h

igh

com

pres

sion

ther

apy

shou

ld b

e ap

plie

d fo

llow

ing

diag

nosi

s of

an

unco

mpl

icat

ed v

enou

s le

g ul

cer

* C

ompr

essi

on th

erap

y sh

ould

onl

y be

app

lied

by

a tr

aine

d pr

actit

ione

r

• C

heck

ank

le c

ircum

fere

nce

mea

sure

s m

ore

than

18c

m

• A

pply

moi

stur

iser

to th

e lo

wer

lim

b

• A

pply

pad

ding

ove

r bon

y pr

omin

ence

s

• A

pply

com

pres

sion

sys

tem

as

per

man

ufac

ture

rs’ g

uide

lines

• R

emov

e ba

ndag

ing

if th

ere

is:

-sl

ippa

ge o

f ban

dage

-de

crea

sed

sens

atio

n of

low

er li

mb

-to

es g

o bl

ue o

r pur

ple,

or l

eg s

wel

ls a

bove

or

bel

ow th

e ba

ndag

e -in

crea

sed

pain

in th

e fo

ot o

r cal

f mus

cle

that

is u

nrel

ieve

d by

leg

elev

atio

n fo

r 30

min

utes

ab

ove

hear

t lev

el

-in

crea

sed

shor

tnes

s of

bre

ath

or d

ifficu

lty

brea

thin

g

• M

onito

r P

rogr

ess:

Tra

ce w

ound

bef

ore

star

ting

com

pres

sion

ther

apy,

then

eve

ry 2

–4 w

eeks

, or

whe

n ra

pid

chan

ges

occu

r

• U

se o

f com

pres

sion

sto

ckin

gs fo

r life

re

duce

s le

g ul

cer r

ecur

renc

e (C

lass

3

(40m

m H

g) if

tole

rate

d, o

r hig

hest

leve

l to

lera

ted

)

* A

trai

ned

prac

titio

ner s

houl

d fit

co

mpr

essi

on s

tock

ings

• R

epla

ce c

ompr

essi

on s

tock

ings

eve

ry

6 m

onth

s

• P

rovi

de e

duca

tion

to c

lient

s an

d ca

rers

on

com

pres

sion

sto

ckin

g ap

plic

atio

n an

d re

mov

al te

chni

ques

• R

efer

to v

ascu

lar s

urge

on if

app

ropr

iate

• M

onito

r reg

ular

ly, e

very

3 m

onth

s

• A

pply

moi

stur

iser

twic

e da

ily

• El

evat

e th

e af

fect

ed li

mb

abov

e he

art

leve

l dai

ly

• En

cour

age

ankl

e an

d ca

lf m

uscl

e ex

erci

ses

• R

epea

t Dop

pler

AB

PI e

very

3 m

onth

s, o

r w

hene

ver c

hang

ing

the

type

of c

ompr

essi

on

ther

apy

Cha

ract

eris

tics

of a

Ven

ous

Leg

Ulc

er

Whe

n to

Ref

er

CR

ICO

S N

o. 0

0213

J

© QUT 2013 17812

His

tory

• M

edic

al

• M

edic

atio

ns

• W

ound

•

Psy

chos

ocia

l / a

ctiv

ities

of d

aily

livi

ng

Char

acte

rist

ics

of t

he

wou

nd (s

ee ta

ble

bel

ow)

Dia

gnos

tic

inve

stig

atio

ns:

• A

ll pa

tient

s w

ith a

leg

ulce

r sho

uld

be

scre

ened

for a

rter

ial d

isea

se, i

nclu

ding

an

Ank

le B

rach

ial P

ress

ure

Inde

x (A

BP

I)*

• R

eass

ess

the

AB

PI e

very

3 m

onth

s or

if c

linic

ally

indi

cate

d

* Com

pres

sion

ther

apy

is c

ontra

indi

cate

d

if th

e A

BP

I is

<0.

8 or

>1.

2

* A

sses

smen

t sho

uld

only

be

unde

rtak

en

by a

trai

ned

heal

th p

ract

ition

er

• Irr

igat

e w

ith w

arm

wat

er o

r nor

mal

sal

ine.

P

at d

ry

• C

lean

the

wou

nd g

ently

(a

void

mec

hani

cal t

raum

a)

• R

emov

e ne

crot

ic o

r dev

italis

ed ti

ssue

(e

.g. a

utol

ytic

deb

ridem

ent)*

• EM

LA® c

ream

can

redu

ce p

ain

asso

ciat

ed

with

deb

ridem

ent

* M

echa

nica

l or s

harp

deb

ridem

ent s

houl

d

only

be

done

by

a tr

aine

d pr

actit

ione

r

• S

elec

t a d

ress

ing

that

will

: -m

aint

ain

a m

oist

wou

nd b

ed -m

anag

e w

ound

exu

date

-pr

otec

t the

sur

roun

ding

ski

n

The

surr

oundin

g sk

in

ofte

n h

as:

Hae

mos

ider

in (b

row

n) s

tain

ing

Hyp

erke

rato

sis

(dry

, flak

y sk

in)

Veno

us s

tasi

s ec

zem

a

Inve

rted

cha

mpa

gne

bottl

e le

g ap

pear

ance

Unc

erta

inty

in d

iagn

osis

Com

plex

ulc

ers

(m

ultip

le a

etio

logy

)

AB

PI <

0.8

or >

1.2

No

redu

ctio

n in

wou

nd

size

with

in 4

wee

ks a

fter

star

ting

com

pres

sion

Det

erio

ratio

n of

ulc

er

Sig

ns o

f inf

ectio

n

Failu

re to

impr

ove

afte

r 3

mon

ths

Art

eria

l Leg

Ulc

er F

low

Cha

rt

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Ass

essm

ent

Wou

nd B

ed M

anag

emen

tM

anag

emen

tP

reve

ntio

n

Ref

eren

ces:

Sco

ttis

h In

terc

olle

giat

e G

uide

lines

Net

wor

k, D

iagn

osis

and

man

agem

ent o

f per

iphe

ral a

rter

ial

dis

ease

. 200

6, E

dinb

urgh

: SIG

N •

Hop

f H e

t al.

Gui

delin

es fo

r the

trea

tmen

t of a

rter

ial i

nsuf

ficie

ncy

ulce

rs. W

ound

Rep

Reg

en, 2

006.

14

(6):6

93-7

10 •

Nat

iona

l Clin

ical

Gui

delin

e C

entr

e, L

ower

lim

b p

erip

hera

l art

eria

l dis

ease

. Dia

gnos

is a

nd m

anag

emen

t. N

ICE

Clin

ical

Gui

delin

e 14

7, 2

012:

Lon

don

•

Hop

f H e

t al.

Gui

delin

es fo

r pre

vent

ion

of lo

wer

ext

rem

ity a

rter

ial u

lcer

s. W

ound

Rep

Reg

en, 2

008.

16

(2):1

75-1

88 •

RN

AO

, Ass

essm

ent a

nd m

anag

emen

t of f

oot u

lcer

s fo

r p

eop

le w

ith d

iab

etes

. 200

5

This

pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of H

ealth

and

Age

ing

unde

r the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

Car

e (E

BPA

C) p

rogr

am

His

tory

• M

edic

al

• M

edic

atio

ns

• W

ound

•

Psy

chos

ocia

l / a

ctiv

ities

of d

aily

livi

ng

Char

acte

rist

ics

of t

he

wou

nd (s

ee ta

ble

bel

ow)

Dia

gnos

tic

inve

stig

atio

ns

All

patie

nts

with

a le

g ul

cer s

houl

d be

scr

eene

d

for a

rter

ial d

isea

se, i

nclu

ding

an

Ank

le B

rach

ial

Pre

ssur

e In

dex

(AB

PI)

* A

sses

smen

t sho

uld

only

be

unde

rtak

en b

y a

trai

ned

heal

th p

rofe

ssio

nal A

rter

ial l

eg u

lcer

s ty

pic

ally

:

• Occ

ur o

n th

e an

terio

r shi

n,

ankl

e bo

nes,

hee

ls o

r toe

s

• Hav

e pa

in w

hich

is re

lieve

d

whe

n le

gs a

re lo

wer

ed b

elow

th

e le

vel o

f the

hea

rt

• Hav

e ‘p

unch

ed o

ut’

wou

nd e

dges

• May

hav

e m

umm

ified

or d

ry

and

blac

k to

es

The

surr

oundin

g sk

in

or t

issu

e of

ten h

as:

• Shi

ny o

r dry

ski

n

• Dev

italis

ed s

oft t

issu

e w

ith d

ry o

r wet

cru

st

• Thi

cken

ed to

e na

ils

• A p

urpl

ish

colo

ur w

hen

the

leg

is lo

wer

ed to

the

grou

nd

• Los

s of

hai

r

• Coo

l ski

n

• C

lean

se th

e w

ound

gen

tly w

ith w

arm

w

ater

or n

orm

al s

alin

e. P

at d

ry.

• In

gen

eral

, deb

ride

necr

otic

or

devi

talis

ed ti

ssue

: how

ever

, do

not

debr

ide

dry

gang

rene

or e

scha

r

* D

ebrid

emen

t sho

uld

be u

nder

take

n on

ly b

y a

trai

ned

heal

th p

rofe

ssio

nal

• M

aint

ain

a m

oist

wou

nd e

nviro

nmen

t, ho

wev

er, i

f dry

gan

gren

e or

esc

har i

s pr

esen

t, it

is b

est l

eft d

ry

• To

pica

l ant

imic

robi

al d

ress

ings

may

be

bene

ficia

l whe

n w

ound

s ar

e ch

roni

cally

or

hea

vily

col

onis

ed

• P

rom

ote

oxyg

enat

ion

thro

ugh

avoi

danc

e of

: -sm

okin

g -de

hydr

atio

n -co

ld -st

ress

and

pai

n

• R

efer

to v

ascu

lar s

urge

on fo

r re

stor

atio

n of

blo

od fl

ow b

y re

vasc

ular

isat

ion,

if a

ppro

pria

te

• En

sure

opt

imal

pai

n m

anag

emen

t st

rate

gies

• R

educ

e ris

k fa

ctor

s: -ce

ase

smok

ing

-co

ntro

l dia

bete

s m

ellit

us -co

ntro

l ele

vate

d lip

ids

-co

ntro

l hyp

erte

nsio

n -an

ti-pl

atel

et th

erap

y -co

ntro

l wei

ght

• R

efer

to v

ascu

lar s

urge

on fo

r as

sess

men

t if a

ppro

pria

te

• E

xerc

ise

the

low

er li

mbs

• P

rote

ct le

gs a

nd fe

et:

-en

sure

sof

t, co

nfor

min

g,

prop

er fi

tting

sho

es - re

fer t

o po

diat

rist f

or g

ener

al fo

otca

re,

orth

odic

s an

d of

fload

ing

as n

eces

sary

- pr

otec

t leg

s (e

.g. p

adde

d eq

uipm

ent,

long

clo

thin

g) -us

e pr

essu

re re

lief d

evic

es e

.g. h

igh

dens

ity fo

am o

r air

cush

ion

boot

s fo

r th

ose

with

lim

ited

mob

ility

• K

eep

the

legs

war

m (e

.g. s

ocks

, rug

s)

• Ea

t a n

utrit

ious

die

t• u

ncer

tain

ty o

f di

agno

sis

• a lo

w A

BP

I < 0

.8 o

r a

high

AB

PI >

1.2

• sym

ptom

s im

pact

on

qual

ity o

f life

• mul

tiple

aet

iolo

gy

• sig

ns o

f inf

ectio

n

• ulc

er a

ppea

rs

isch

aem

ic

• fai

lure

to h

eal

Cha

ract

eris

tics

of a

n A

rter

ial L

eg U

lcer

Whe

n to

Ref

er

CR

ICO

S N

o. 0

0213

J

© QUT 2013 17812

Dia

betic

Foo

t Ulc

er F

low

Cha

rt

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Ass

essm

ent

Wou

nd B

ed M

anag

emen

tM

anag

emen

tP

reve

ntio

n

This

pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of H

ealth

and

Age

ing

unde

r the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

Car

e (E

BPA

C) p

rogr

am

Dia

bet

ic u

lcer

s ty

pic

ally

:

Occ

ur o

n th

e so

le o

f the

foot

or o

ver p

ress

ure

poin

ts

e.g.

toes

The

wou

nd b

ed c

an b

e sh

allo

w o

r dee

p, p

rodu

cing

lo

w to

mod

erat

e am

ount

s of

exu

date

The

surr

ound

ing

skin

is u

sual

ly d

ry, t

hin

and

fre

quen

tly h

as c

allo

us fo

rmat

ion

• R

educ

e pr

essu

re –

offl

oad

pres

sure

poi

nts

e.g.

use

cru

tche

s, w

heel

chai

rs, c

usto

m s

hoes

or

inse

rts,

ort

hotic

wal

kers

, dia

betic

boo

ts, o

r tot

al

cont

act c

asts

• P

rom

ote

oxyg

enat

ion

of th

e w

ound

by

avoi

ding

de

hydr

atio

n, s

mok

ing,

col

d, s

tress

and

pai

n

• O

ptim

ise

gluc

ose

cont

rol

• R

egul

arly

doc

umen

t pro

gres

s in

hea

ling

• R

e-ev

alua

te tr

eatm

ent i

f fai

lure

to a

chie

ve

40%

ulc

er s

ize

redu

ctio

n af

ter 4

wee

ks

• A

mul

tidis

cipl

inar

y te

am is

nee

ded

; inc

lude

po

diat

rists

, ort

hotis

ts, d

ietit

ians

, GP

s, w

ound

ca

re n

urse

s an

d en

docr

inol

ogis

ts

• C

onsu

lt re

mot

e ex

pert

adv

ice

with

dig

ital

imag

ing

for c

lient

s liv

ing

in re

mot

e ar

eas

• A

sses

s al

l clie

nts

with

dia

bete

s fo

r PA

D,

neur

opat

hy a

nd fo

ot d

efor

mity

and

cla

ssify

th

e le

vel o

f ris

k

• P

rote

ctiv

e fo

otw

ear i

s re

quire

d fo

r tho

se a

t ris

k, i.

e. w

ith P

AD

, neu

ropa

thy,

cal

lus,

foot

de

form

ity a

nd/o

r pre

viou

s ul

cera

tion

• O

ffloa

d pr

essu

re p

oint

s as

det

aile

d un

der

‘Man

agem

ent’

• P

ract

ise

good

foot

car

e an

d da

ily

insp

ectio

n of

feet

• En

sure

an

annu

al fo

ot e

xam

inat

ion

by a

he

alth

pro

fess

iona

l (3

– 6

mon

thly

if a

t m

oder

ate

or h

igh

risk)

• M

onito

r and

opt

imis

e bl

ood

gluc

ose

leve

ls

• Q

uit s

mok

ing

Cha

ract

eris

tics

of a

Dia

betic

Foo

t Ulc

er

Unc

erta

inty

of d

iagn

osis

Ther

e is

a lo

w o

r hig

h A

BP

I

Sym

ptom

s im

pact

on

qual

ity o

f life

Com

plic

ated

ulc

ers

e.g.

mul

tiple

aet

iolo

gy

Sig

ns o

f inf

ectio

n or

wou

nd p

robe

s to

bon

e

No

prog

ress

in h

ealin

g or

det

erio

ratio

n of

ulc

er

Whe

n to

Ref

er

CR

ICO

S N

o. 0

0213

J

© QUT 2013 17812

His

tory

• M

edic

al

• M

edic

atio

ns

• W

ound

•

Psy

chos

ocia

l / a

ctiv

ities

of d

aily

livi

ng

Char

acte

rist

ics

of t

he

wou

nd

• U

se a

val

idat

ed c

lass

ifica

tion

tool

Insp

ect

for

foot

def

orm

itie

s

Dia

gnos

tic

inve

stig

atio

ns*

• S

cree

n al

l clie

nts

for p

erip

hera

l art

eria

l di

seas

e (P

AD

), in

clud

ing

an a

nkle

bra

chia

l pr

essu

re (A

BP

I)

• A

n A

BP

I les

s th

an 0

.9 in

dica

tes

arte

rial

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ase

• A

BP

I gre

ater

than

1.2

indi

cate

s a

need

for

furt

her i

nves

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• U

se m

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lam

ent t

estin

g to

ass

ess

for l

oss

of s

ensa

tion

and

neur

opat

hy

* A

sses

smen

t sho

uld

only

be

unde

rtak

en

by a

trai

ned

heal

th p

rofe

ssio

nal

• C

lean

se th

e w

ound

with

a n

eutra

l, no

n-irr

itatin

g so

lutio

n e.

g. w

arm

wat

er

or n

orm

al s

alin

e

• C

lean

se w

ound

bed

gen

tly to

avo

id tr

aum

a

• R

emov

e ne

crot

ic o

r dev

italis

ed ti

ssue

, unl

ess

reva

scul

aris

atio

n is

nee

ded*

* M

echa

nica

l or s

harp

deb

ridem

ent s

houl

d

only

be

done

by

a tr

aine

d he

alth

pro

fess

iona

l

• S

elec

t a d

ress

ing

whi

ch w

ill:

-m

aint

ain

a m

oist

wou

nd e

nviro

nmen

t (e

xcep

t whe

re d

ry g

angr

ene

or

esch

ar is

pre

sent

) -pr

otec

t the

sur

roun

ding

ski

n -m

anag

e w

ound

exu

date

-to

pica

l ant

imic

robi

al d

ress

ings

will

help

ch

roni

cally

or h

eavi

ly c

olon

ised

wou

nds

Ref

eren

ces:

Ste

ed D

L et

al.

Gui

delin

es fo

r the

trea

tmen

t of d

iabe

tic u

lcer

s. W

ound

Rep

Reg

en

2006

. 14

(6):6

80-6

92 •

Ste

ed D

L et

al.

Gui

delin

es fo

r the

pre

vent

ion

of d

iabe

tic

ulce

rs. W

ound

Rep

Reg

en 2

008.

16

(2):1

69-1

74 •

Nat

iona

l Evi

den

ce-B

ased

G

uid

elin

e on

Pre

vent

ion,

Iden

tifica

tion

and

Man

agem

ent o

f Foo

t Com

plic

atio

ns

in D

iab

etes

. Mel

bour

ne A

ustr

alia

201

1 •

Sco

ttis

h In

terc

olle

giat

e G

uide

lines

N

etw

ork

Man

agem

ent o

f dia

bet

es. E

dinb

urgh

: SIG

N 2

010

• R

NA

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sses

smen

t an

d M

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emen

t of F

oot U

lcer

s fo

r P

eop

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ith D

iab

etes

. Tor

onto

: RN

AO

200

5 •

M

cInt

osh

A e

t al.

Pre

vent

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and

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agem

ent o

f Foo

t Pro

ble

ms

in T

ype

2 D

iab

etes

. S

heffi

eld

: NIC

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03

Mon

ofila

men

t te

stin

g to

che

ck

sens

atio

n

Pre

ssur

e In

jury

Flo

w C

hart

Pre

ssur

e ul

cer

clas

sific

atio

n sy

stem

*

Ref

eren

ces:

AW

MA

. Pan

Pac

ific

Clin

ical

Pra

ctic

e G

uid

elin

e fo

r P

reve

ntio

n an

d M

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ress

ure

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ry.

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orne

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Mal

vern

, PA

: AA

WC

201

0 •

Ste

chm

iller

et a

l. G

uide

lines

for p

reve

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n of

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ssur

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cers

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nd

Rep

Reg

en 2

008.

16:

151-

168

• W

OC

N. G

uid

elin

e fo

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n an

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ress

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ount

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rel N

J:W

OC

N 2

010

• R

NA

O. R

isk

asse

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ent a

nd p

reve

ntio

n of

pre

ssur

e ul

cers

. (R

evis

ed).

Toro

nto,

ON

: RN

AO

201

1 •

NIC

E. T

he u

se o

f pre

ssur

e-re

lievi

ng d

evic

es fo

r th

e p

reve

ntio

n of

pre

ssur

e ul

cers

. Lon

don:

RC

N 2

004

• R

oyal

Col

lege

of N

ursi

ng. M

anag

emen

t of

pre

ssur

e ul

cers

. Lon

don:

RC

N a

nd N

ICE

2005

• W

hitn

ey e

t al.

Gui

delin

es fo

r tre

atm

ent o

f pre

ssur

e ul

cers

. Wou

nd R

ep R

egen

200

6. 1

4:66

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ry ri

sk

asse

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ent

(e.g

. Wat

erlo

w, B

rade

n)

-on

adm

issi

on -at

regu

lar i

nter

vals

-up

on a

cha

nge

in h

ealth

sta

tus

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a cl

ient

is fo

und

to b

e ‘a

t ris

k’, a

sses

s sk

in a

t lea

st d

aily

• S

uspe

cted

sta

ge 1

pre

ssur

e in

jurie

s sh

ould

be

reas

sess

ed 2

0 m

inut

es a

fter

pres

sure

is re

lieve

d

• R

egul

arly

ass

ess

for p

ain

and

deve

lop

a

pain

man

agem

ent p

lan

if ap

prop

riate

Red

uced

phy

sica

l mob

ility

Loss

of s

ensa

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ired

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ition

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evel

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Acu

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illnes

s

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igat

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arm

cle

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ater

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orm

al s

alin

e

• C

lean

the

wou

nd g

ently

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emov

e ne

crot

ic o

r dev

italis

ed ti

ssue

*

*M

echa

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l or s

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ridem

ent s

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d

onl

y be

don

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trai

ned

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icia

ns

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elec

t a d

ress

ing

whi

ch w

ill:

-m

aint

ain

a m

oist

wou

nd b

ed -m

anag

e w

ound

exu

date

-pr

otec

t the

sur

roun

ding

ski

n -m

inim

ise

shea

r, fri

ctio

n &

pre

ssur

e -to

pica

l neg

ativ

e pr

essu

re m

ay b

enefi

t st

age

III &

IV u

lcer

s

• U

se a

hig

h sp

ecifi

catio

n re

activ

e or

ac

tive

supp

ort s

urfa

ce fo

r clie

nts

with

pr

essu

re in

jurie

s

• S

tage

III,

IV, u

nsta

geab

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r dee

p tis

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ries

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n al

tern

atin

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w p

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r ai

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obs

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and

a

repo

sitio

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regi

me

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void

pos

ition

ing

dire

ctly

on

bony

pr

omin

ence

s or

pre

ssur

e in

jurie

s

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void

she

ar a

nd fr

ictio

n

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mit

the

amou

nt o

f tim

e th

e he

ad o

f bed

is

ele

vate

d

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se p

illow

s an

d fo

am w

edge

s to

ele

vate

or

repo

sitio

n bo

ny p

rom

inen

ces

e.g.

hee

ls, h

ips

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rovi

de h

igh

prot

ein

nutri

tiona

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plem

ents

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clud

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ith a

sta

ge 2

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ter p

ress

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ry

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cipl

inar

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ch is

nee

ded,

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clud

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hysi

othe

rapy

, occ

upat

iona

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rapy

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ietit

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ical

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d m

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stag

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ocat

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tis

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ex

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urro

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kin,

in

terv

entio

ns)

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gres

s an

d ou

tcom

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in

terv

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nclu

ding

use

of

a v

alid

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hea

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scal

e

Ris

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ctor

s fo

r a

Pre

ssur

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jury

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umen

t

heal

thy

skin

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pions

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U

nsta

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if br

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pto

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oon

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This

pro

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nded

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Aus

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ernm

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epar

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ealth

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NP

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ww

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This is a guide only and does not replace clinical judgment

References:

AWMA, Standards for Wound Management. 2nd ed 2010, Osborne Park, WA: Cambridge Media


Dorner B et al., the National Pressure Ulcer Advisory Panel, The role of nutrition in pressure ulcer prevention and treatment, 2009, NPUAP

AWMA, Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury 2012, Osborne Park, WA: Cambridge Media

LeBlanc K, Baranoski S, Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care, 2011. 24(9S):2-15

NHMRC. Dietary Guidelines for Australian Adults. 2003 Canberra: Commonwealth of Australia

Woodward et al. (Eds) Nutrition and Wound Healing. 2008 Nestle Healthcare Nutrition

Woodward M. Guidelines to effective hydration in aged care facilities. 2007. www.hydralyte.com/pdf/aged_care_brochure.pdf


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Phone: + 61 7 3138 6000 or Fax: +61 7 3138 6030 or Email: [email protected] Email (Wound Healing): [email protected]

CRICOS No. 00213J

www.ihbi.qut.edu.au

This Project is funded by the Australian Government Department of Health and Ageing under the Encouraging Better Practice in Aged Care (EBPAC) program.


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Information for health professionals


3.2.4 Brochures for Health Professionals

The resource package includes a wide range of brochures for health professionals as well as clients, family and carers. The brochures are framed to match the audience. For example the brochures for the health professionals can be used as a clinical reference tool whereas the brochures for clients, family and carers use simplified language to provide wound sufferers and their carers with information about their wounds and management of the wounds.

• Skin Tears





• Wound care

• Wound Assessment



Samples of all brochures are included at the back of this booklet


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References:

WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. London: MEP Ltd 2004

Australian Wound Management Association. Standards for wound management. 2nd ed. Osborne Park, WA: Cambridge Media 2010

JBI Wound Healing and Management Node Group. Chronic wound management. (JBI) Best Practice: evidence-based information sheets for health professionals 2011

Australian Wound Management Association. Position Document: Bacterial impact on wound healing: from contamination to infection. AWMA 2011

Hopf H et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair and Regeneration 2006. 14(6):693-710

WUWHS. Principles of best practice: Wound exudate and the role of dressings. A consensus document. London: MEP Ltd 2007.


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CRICOS No. 00213J

www.ihbi.qut.edu.au



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Wound AssessmentDocumentation should provide enough information to:

• monitor progress in wound healing

• evaluate the effectiveness of management

• guide management and prevention plans


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References:


Australian Wound Management Assoc. Standards for wound management. 2nd ed. Osborne Park, WA: Cambridge Media 2010

JBI Wound Healing and Management Node Group. Chronic wound management. (JBI) Best Practice: evidence-based information sheets for health professionals 2011

Australian Wound Management Assoc. Position Document: Bacterial impact on wound healing: from contamination to infection. AWMA 2011

Hopf H et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair and Regeneration 2006. 14(6): 693-710

WUWHS. Principles of best practice: Wound exudate and the role of dressings. London: MEP Ltd 2007.

Medical Advisory Secretariat. Community-based care for chronic wound management: An evidence-based analysis. Ontario Health Technology Assessment Series 2009.9(18)

Whitney J et al. Guidelines for the treatment of pressure ulcers. Wound Repair and Regeneration 2006.14(6):663-679


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CRICOS No. 00213J

www.ihbi.qut.edu.au



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Wound Care


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References:

Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Osborne Park, WA: Cambridge Media 2012


Stechmiller et al. Guidelines for the prevention of pressure ulcers. Wound Rep Regeneration 2008. 16:151-68

RNAO. Risk assessment and prevention of pressure ulcers. (Revised). Toronto: RNAO 2011

NICE. The use of pressure-relieving devices for the prevention of pressure ulcers in primary and secondary care. London: Royal College of Nursing 2004

Royal College of Nursing. The management of pressure ulcers in primary and secondary care: A clinical practice guideline. London: RCN & NICE 2005

Whitney et al. Guidelines for the treatment of pressure ulcers. Wound Rep Regeneration 2006. 14:663-79


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CRICOS No. 00213J

www.ihbi.qut.edu.au



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Pressure Injuries


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References:



National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes. Melbourne Australia: NHMRC 2011

Scottish Intercollegiate Guidelines Network (SIGN) Management of diabetes. A national clinical guideline. Edinburgh, Scotland: SIGN 2010

Registered Nurses’ Association of Ontario (RNAO) Assessment and Management of Foot Ulcers for People with Diabetes. Toronto: RNAO 2005

McIntosh A et al. Prevention and Management of Foot Problems in Type 2 Diabetes. Sheffield: University of Sheffield: NICE 2003


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CRICOS No. 00213J

www.ihbi.qut.edu.au



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References:

Scottish Intercollegiate Guidelines Network. Diagnosis and management of peripheral arterial disease. 2006, Edinburgh: SIGN

Hopf H et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair and Regeneration, 2006. 14(6):693-710

National Clinical Guideline Centre. Lower limb peripheral arterial disease. 2012, London: NICE

Hopf H et al. Guidelines for prevention of lower extremity arterial ulcers. Wound Repair and Regeneration, 2008. 16(2):175-188

RNAO. Assessment and management of foot ulcers for people with diabetes. 2005, Ontario: RNAO


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CRICOS No. 00213J

www.ihbi.qut.edu.au



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Arterial Leg Ulcers


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References:

Royal College of Nursing (RCN), Clinical practice guidelines: The management of patients with venous leg ulcers 2006, London: RCN Institute, Centre for Evidence based Nursing, University of York.

Registered Nurses’ Association of Ontario (RNAO), Assessment and Management of Venous Leg Ulcers. March 2004 ed. RNAO 2004, Toronto, Ontario: RNAO.

Australian Wound Management Association (AWMA), Australian and New Zealand Clinical Practice Guidelines for Prevention and Management of Venous Leg Ulcers, 2011, AWMA: Barton. ACT.

Scottish Intercollegiate Guidelines Network (SIGN), Management of chronic venous leg ulcers. A national clinical guideline 2010, SIGN: Edinburgh.


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CRICOS No. 00213J

www.ihbi.qut.edu.au



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Venous Leg Ulcers


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Products listed or pictured are examples only and do not represent an endorsement of any

company or particular product

References:

Ayello E, Sibbald R, Preventing pressure ulcers and skin tears, in Evidence-based geriatric nursing protocols for best practice, Capezuti E, et al., Editors. 2008, Springer: New York. p.403-29

LeBlanc K, Baranoski S, Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Advances in Skin and Wound Care, 2011. 24(9 Suppl): 2-15

Ratliff C, Fletcher K, Skin Tears: A review of the evidence to support prevention and treatment. Ostomy Wound Management, 2007 53(3) www.o-wm.com/article/6968

Carville K et al., STAR: A consensus for skin tear classification. Primary Intention, 2007. 15(1):18–28

Joanna Briggs Institute, Topical skin care in aged care facilities. Best Practice 2007, 11.

Best Practice Statement: Care of the Older Person’s Skin Wounds UK 2012, 2nd ed www.woundsinternational.com/pdf/content_10608.pdf


promoting



CRICOS No. 00213J

www.ihbi.qut.edu.au



promoting


Skin Tears

3

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Pro

duc

ts li

sted

or p

ictu

red

are

exam

ple

s on

ly

and

do

not r

epre

sent

an

end

orse

men

t of a

ny

com

pan

y or

par

ticul

ar p

rod

uct

Ref

eren

ces:

Aye

llo E

, Sib

bald

R, P

reve

ntin

g p

ress

ure

ulce

rs a

nd s

kin

tear

s,

in E

vid

ence

-bas

ed g

eria

tric

nur

sing

pro

toco

ls fo

r b

est p

ract

ice,

C

apez

uti E

, et a

l., E

dito

rs. 2

008,

Spr

inge

r: N

ew Y

ork.

p.4

03-2

9

LeB

lanc

K, B

aran

oski

S, S

kin

tear

s: s

tate

of t

he s

cien

ce:

cons

ensu

s st

atem

ents

for

the

pre

vent

ion,

pre

dic

tion,

ass

essm

ent,

and

trea

tmen

t of s

kin

tear

s. A

dva

nces

in S

kin

and

Wou

nd C

are,

20

11. 2

4(9

Sup

pl):

2-15

Rat

liff C

, Fle

tche

r K, S

kin

Tear

s: A

rev

iew

of t

he e

vid

ence

to

sup

por

t pre

vent

ion

and

trea

tmen

t. O

stom

y W

ound

Man

agem

ent,

2007

53

(3)

ww

w.o

-wm

.co

m/a

rtic

le/6

968

Car

ville

K e

t al.,

STA

R: A

con

sens

us fo

r sk

in te

ar c

lass

ifica

tion.

P

rimar

y In

tent

ion,

200

7. 1

5(1

):18

–28

Joan

na B

riggs

Inst

itute

, Top

ical

ski

n ca

re in

age

d ca

re fa

cilit

ies.

B

est P

ract

ice

2007

, 11.

Bes

t Pra

ctic

e S

tate

men

t: C

are

of th

e O

lder

Per

son’

s S

kin

Wou

nds

UK

201

2, 2

nd e

d w

ww

.wo

un

dsi

nte

rnat

ion

al.c

om

/pd

f/co

nte

nt_

1060

8.p

df

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustr

alia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

au

Thi

s P

roje

ct is

fund

ed b

y th

e A

ustr

alia

n G

over

nmen

t D

epar

tmen

t of H

ealth

and

Ag

eing

und

er t

he E

nco

urag

ing

Bet

ter

Pra

ctic

e in

Ag

ed C

are

(EB

PA

C) p

rog

ram

.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Info

rmat

ion

for h

ealt

h p

rofe

ssio

nal

s

Ski

n Te

ars

Ski

n Te

ars

What

is a

ski

n t

ear?

A s

kin

tear

is “

a tr

aum

atic

wou

nd ..

. as

a re

sult

of fr

ictio

n al

one

or s

hear

ing

and

frict

ion

forc

es

whi

ch s

epar

ate

the

epid

erm

is fr

om th

e de

rmis

(p

artia

l thi

ckne

ss w

ound

), or

whi

ch s

epar

ate

both

the

epid

erm

is a

nd d

erm

is fr

om u

nder

lyin

g st

ruct

ures

(ful

l-thi

ckne

ss w

ound

)”

(Pay

ne &

Mar

tin 1

993

).

Ris

k fa

ctor

s fo

r sk

in t

ears

• H

isto

ry o

f pre

viou

s sk

in te

ars

• B

ruis

ing,

dis

colo

ured

, thi

n or

frag

ile s

kin

• A

dvan

ced

age

• P

oor n

utrit

iona

l sta

tus

• C

ogni

tive

impa

irmen

t or d

emen

tia

• D

epen

denc

y

• M

any

or c

erta

in m

edic

atio

ns e

.g. s

tero

ids

• Im

paire

d m

obilit

y

• D

ry s

kin

/ de

hydr

atio

n

• P

rese

nce

of fr

ictio

n, s

hear

ing,

pre

ssur

e

• Im

paire

d se

nsor

y pe

rcep

tion

• C

orm

orbi

ditie

s e.

g. re

nal,

card

iova

scul

ar d

isea

se

Ski

n t

ear

pre

venti

on s

trat

egie

s

• A

sses

s sk

in re

gula

rly a

nd im

plem

ent a

pr

even

tion

prot

ocol

for t

hose

at r

isk

• U

se a

n em

ollie

nt s

oap

subs

titut

e

• A

pply

moi

stur

iser

to th

e sk

in tw

ice

daily

• U

se p

rope

r lift

ing

and

tran

sfer

tech

niqu

es

• U

se c

autio

n w

hen

bath

ing

and

dres

sing

• A

void

dire

ct c

onta

ct th

at w

ill pu

ll th

e sk

in,

e.g.

use

slid

e sh

eets

• P

rote

ct fr

agile

ski

n—us

e lim

b pr

otec

tors

an

d/o

r lon

g sl

eeve

s or

pan

ts

• P

ad o

r cus

hion

equ

ipm

ent a

nd fu

rnitu

re

(e.g

. bed

rails

, whe

elch

airs

)

• U

se p

illow

s (s

atin

or s

ilk c

over

s re

duce

fri

ctio

n an

d sh

ear)

to p

ositi

on p

eopl

e w

ho

are

less

mob

ile

• A

void

tape

s or

adh

esiv

es, u

se tu

bula

r re

tent

ion

band

ages

and

sof

t silic

one

dres

sing

s to

avo

id te

arin

g th

e sk

in

• P

rovi

de a

saf

e en

viro

nmen

t

Ski

n t

ear

man

agem

ent

• C

ontr

ol b

leed

ing

• G

ently

irrig

ate

the

wou

nd w

ith w

arm

cle

an

wat

er o

r sal

ine.

Cle

an u

nder

the

flap

to re

mov

e de

bris

or c

lots

. Pat

dry

sur

roun

ding

ski

n

• R

ealig

n an

y sk

in o

r flap

by

rollin

g sk

in w

ith

moi

st c

otto

n bu

d. D

o no

t str

etch

to ‘m

ake

it fit

’

• C

lass

ify th

e w

ound

usi

ng a

ski

n te

ar

clas

sific

atio

n sy

stem

• If

brui

sed,

bro

ken

or d

isco

lour

ed s

kin

is

pres

ent,

reas

sess

with

in 4

8 ho

urs

• A

pply

a lo

w-a

dher

ent d

ress

ing

to a

void

trau

ma

e.g.

sof

t silic

ones

. Avo

id u

sing

tape

• E

xten

d dr

essi

ng o

ver w

ound

edg

e by

at

leas

t 2cm

. Dra

w a

n ar

row

on

top

of th

e dr

essi

ng to

indi

cate

dire

ctio

n fo

r rem

oval

• Le

ave

in p

lace

for 5

—7

days

, or c

hang

e if

ther

e is

75%

str

iket

hrou

gh le

akag

e vi

sibl

e

• A

pply

lim

b pr

otec

tor o

r tub

ular

rete

ntio

n ba

ndag

e to

hol

d dr

essi

ng in

pla

ce

• D

ocum

ent s

kin

tear

cat

egor

y, lo

catio

n,

trea

tmen

t and

pre

vent

ion

stra

tegi

es

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

Roy

al C

olle

ge o

f Nur

sing

(RC

N),

Clin

ical

pra

ctic

e gu

idel

ines

: Th

e m

anag

emen

t of p

atie

nts

with

ven

ous

leg

ulce

rs 2

006,

Lo

ndon

: RC

N In

stitu

te, C

entr

e fo

r Evi

denc

e ba

sed

Nur

sing

, U

nive

rsity

of Y

ork.

Reg

iste

red

Nur

ses’

Ass

ocia

tion

of O

ntar

io (R

NA

O),

Ass

essm

ent

and

Man

agem

ent o

f Ven

ous

Leg

Ulc

ers.

Mar

ch 2

004

ed. R

NA

O

2004

, Tor

onto

, Ont

ario

: RN

AO

.

Aus

tral

ian

Wou

nd M

anag

emen

t Ass

ocia

tion

(AW

MA

), A

ustr

alia

n an

d N

ew Z

eala

nd C

linic

al P

ract

ice

Gui

del

ines

for

Pre

vent

ion

and

Man

agem

ent o

f Ven

ous

Leg

Ulc

ers,

201

1, A

WM

A: B

arto

n. A

CT.

Sco

ttis

h In

terc

olle

giat

e G

uide

lines

Net

wor

k (S

IGN

), M

anag

emen

t of

chr

onic

ven

ous

leg

ulce

rs. A

nat

iona

l clin

ical

gui

del

ine

2010

, S

IGN

: Edi

nbur

gh.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustr

alia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

au

Thi

s P

roje

ct is

fund

ed b

y th

e A

ustr

alia

n G

over

nmen

t D

epar

tmen

t of H

ealth

and

Ag

eing

und

er t

he E

nco

urag

ing

Bet

ter

Pra

ctic

e in

Ag

ed C

are

(EB

PA

C) p

rog

ram

.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Info

rmat

ion

for h

ealt

h p

rofe

ssio

nal

s

Veno

us L

eg U

lcer

s

Veno

us L

eg U

lcer

s

Ass

essm

ent

• M

easu

re a

n A

nkle

Bra

chia

l Pre

ssur

e In

dex

(AB

PI)

on a

ll cl

ient

s w

ith a

leg

ulce

r

• A

n A

BP

I sho

uld

only

be

unde

rtak

en b

y he

alth

pr

actit

ione

rs w

ith tr

aini

ng

• A

BP

Is s

houl

d be

repe

ated

:

-w

hene

ver s

tart

ing

com

pres

sion

ther

apy

-w

hene

ver c

hang

ing

type

of c

ompr

essi

on

-if

an u

lcer

det

erio

rate

s or

fails

to p

rogr

ess

-ev

ery

3 m

onth

s

• R

egul

arly

mea

sure

the

ulce

r, e

very

4 w

eeks

or

as c

linic

ally

indi

cate

d to

mon

itor p

rogr

ess

• R

efer

to a

spe

cial

ist i

f:

-th

ere

is u

ncer

tain

ty in

dia

gnos

is

-th

ere

is a

low

or h

igh

AB

PI

(<0.

9 or

>1.

2)

-ul

cers

of c

ompl

ex a

etio

logy

-si

gns

of in

fect

ion

or d

eter

iora

tion

-fa

ilure

to im

prov

e af

ter t

hree

mon

ths

Man

agem

ent

• M

ultil

ayer

com

pres

sion

ban

dagi

ng is

the

first

line

of t

reat

men

t for

unc

ompl

icat

ed

veno

us u

lcer

s

• C

ompr

essi

on th

erap

y sh

ould

be

appl

ied

by a

trai

ned

prac

titio

ner

• P

rote

ctiv

e pa

ddin

g sh

ould

be

used

ove

r bon

y pr

omin

ence

s w

hen

appl

ying

com

pres

sion

• D

ress

ings

sho

uld

be s

impl

e, lo

w-a

dher

ent,

cost

effe

ctiv

e an

d ac

cept

able

to th

e in

divi

dual

• A

void

pro

duct

s th

at c

omm

only

cau

se s

kin

sens

itivi

ty (e

.g. l

anol

in, p

heno

l alc

ohol

)

• S

peci

alis

t leg

ulc

er c

linic

s ar

e re

com

men

ded

as th

e op

timal

com

mun

ity h

ealth

ser

vice

Venou

s le

g ulc

ers

typic

ally

:

• oc

cur o

n th

e lo

wer

third

of t

he le

g

• ar

e us

ually

sha

llow

• ha

ve ir

regu

lar,

slop

ing

wou

nd m

argi

ns

• pr

oduc

e m

oder

ate

to h

eavy

exu

date

• pa

in is

relie

ved

by e

leva

tion

of th

e le

gs

Pre

venti

on

• U

se o

f com

pres

sion

sto

ckin

gs fo

r life

re

duce

s le

g ul

cer r

ecur

renc

e

• C

ompr

essi

on s

tock

ings

sho

uld

be m

easu

red

and

fitte

d by

a tr

aine

d pr

actit

ione

r

• R

epla

ce c

ompr

essi

on s

tock

ings

eve

ry

six

mon

ths

• Te

achi

ng p

eopl

e ho

w to

app

ly th

eir s

tock

ings

is

ess

entia

l

• A

var

iety

of s

tock

ing

appl

icat

ors

are

avai

labl

e

• S

trat

egie

s to

pre

vent

recu

rren

ce a

lso

incl

ude:

-ve

nous

inve

stig

atio

n an

d su

rger

y

-re

gula

r fol

low

-up

and

skin

che

cks

-lo

wer

lim

b ex

erci

ses

-el

evat

ion

of lo

wer

lim

bs a

bove

hea

rt le

vel

-en

surin

g op

timal

nut

ritio

n an

d hy

drat

ion

Venou

s ulc

ers

are

the

mos

t co

mm

on t

ype

of

leg

ulc

er a

nd a

ccou

nt

for

60

-70%

of

all l

eg

ulc

ers

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

Sco

ttis

h In

terc

olle

giat

e G

uide

lines

Net

wor

k. D

iagn

osis

and

m

anag

emen

t of p

erip

hera

l art

eria

l dis

ease

. 200

6, E

dinb

urgh

: S

IGN

Hop

f H e

t al.

Gui

delin

es fo

r the

trea

tmen

t of a

rter

ial i

nsuf

ficie

ncy

ulce

rs. W

ound

Rep

air

and

Reg

ener

atio

n, 2

006.

14

(6):6

93-7

10

Nat

iona

l Clin

ical

Gui

delin

e C

entr

e. L

ower

lim

b p

erip

hera

l art

eria

l d

isea

se. 2

012,

Lon

don:

NIC

E

Hop

f H e

t al.

Gui

delin

es fo

r pre

vent

ion

of lo

wer

ext

rem

ity a

rter

ial

ulce

rs. W

ound

Rep

air

and

Reg

ener

atio

n, 2

008.

16

(2):1

75-1

88

RN

AO

. Ass

essm

ent a

nd m

anag

emen

t of f

oot u

lcer

s fo

r p

eop

le

with

dia

bet

es. 2

005,

Ont

ario

: RN

AO

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustr

alia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

au

Thi

s P

roje

ct is

fund

ed b

y th

e A

ustr

alia

n G

over

nmen

t D

epar

tmen

t of H

ealth

and

Ag

eing

und

er t

he E

nco

urag

ing

Bet

ter

Pra

ctic

e in

Ag

ed C

are

(EB

PA

C) p

rog

ram

.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Info

rmat

ion

for h

ealt

h p

rofe

ssio

nal

s

Art

eria

l Leg

Ulc

ers

Art

eria

l Leg

Ulc

ers

Ass

essm

ent

• A

ll cl

ient

s sh

ould

be

scre

ened

for a

rter

ial

dise

ase,

incl

udin

g pe

dal p

ulse

s an

d A

nkle

B

rach

ial P

ress

ure

Inde

x (A

BP

I)

• A

sses

smen

t of l

eg u

lcer

s an

d A

BP

I sho

uld

only

be

und

erta

ken

by tr

aine

d pr

actit

ione

rs

• A

n A

BP

I <0.

9 is

indi

cativ

e of

art

eria

l dis

ease

an

d an

AB

PI >

1.2

requ

ires

inve

stig

atio

n

• O

ther

sig

ns o

f per

iphe

ral v

ascu

lar d

isea

se:

-lo

ss o

f hai

r, sh

iny,

dry

or c

ool s

kin

-m

umm

ified

or b

lack

toes

-de

vita

lised

sof

t tis

sue

with

dry

or w

et c

rust

-th

icke

ned

toe

nails

-pu

rple

col

our o

f lim

b in

dep

ende

nt p

ositi

on

• R

efer

to a

spe

cial

ist w

hen

ther

e is

:

-un

cert

aint

y in

dia

gnos

is o

r abn

orm

al A

BP

I

-sy

mpt

oms

limit

lifes

tyle

and

qua

lity

of li

fe

-si

gns

of in

fect

ion,

det

erio

ratio

n or

isch

aem

ia

Man

agem

ent

• R

evas

cula

risat

ion

is th

e m

etho

d m

ost l

ikel

y to

he

al a

nd p

reve

nt a

rter

ial l

eg u

lcer

s, if

sur

gery

is

appr

opria

te fo

r the

clie

nt

• P

rom

ote

oxyg

enat

ion

of w

ound

env

ironm

ent –

av

oid

cold

, deh

ydra

tion,

str

ess

and

pain

• D

ress

ings

sho

uld

mai

ntai

n a

moi

st

envi

ronm

ent,

how

ever

, dry

gan

gren

e or

esc

har

is b

est l

eft d

ry u

ntil

reva

scul

aris

atio

n

• If

dry

gang

rene

or e

scha

r is

pres

ent,

do n

ot

debr

ide

until

re-e

stab

lishm

ent o

f art

eria

l flow

• D

ebrid

emen

t sho

uld

be u

nder

take

n by

hea

lth

prof

essi

onal

s w

ith tr

aini

ng o

r exp

ertis

e

• To

pica

l ant

imic

robi

al d

ress

ings

may

hel

p if

wou

nds

are

chro

nica

lly o

r hea

vily

col

onis

ed

• H

yper

baric

oxy

gen

ther

apy

may

be

help

ful f

or

clie

nts

unab

le to

be

reva

scul

aris

ed a

nd w

hose

ul

cer i

s no

t hea

ling

• Li

fest

yle

mod

ifica

tions

, edu

catio

n an

d m

edic

atio

ns a

s ne

cess

ary

are

impo

rtan

t

Art

eria

l leg

ulc

ers

typic

ally

:

• oc

cur o

ver t

oes

or b

ony

prom

inen

ces

• ar

e pa

le g

rey

or y

ello

w in

col

our

• ha

ve a

‘pu

nche

d ou

t’ ap

pear

ance

• ha

ve m

inim

al e

xuda

te

• ar

e ve

ry p

ainf

ul, p

artic

ular

ly w

hen

legs

are

ele

vate

d

Pre

venti

on

• R

educ

e ris

k fa

ctor

s: -ce

ase

smok

ing

-op

timis

e bl

ood

gluc

ose

leve

ls

-co

ntro

l lip

id le

vels

and

hy

pert

ensi

on

-an

ti-pl

atel

et th

erap

y

-co

ntro

l wei

ght

• E

xerc

ise

low

er li

mbs

to

incr

ease

art

eria

l flow

• P

rote

ct lo

wer

ext

rem

ities

, inc

ludi

ng:

-so

ft, c

onfo

rmin

g, w

ell fi

ttin

g sh

oes,

or

thot

ics

and

pres

sure

off-

load

ing

as n

eede

d

-le

g pr

otec

tion

to a

void

inju

ry

-pr

otec

tion

of d

igits

and

hee

ls

-us

e of

effe

ctiv

e pr

essu

re re

lievi

ng d

evic

es

-ta

ke e

xtre

me

care

whe

n cu

ttin

g na

ils,

pref

erab

ly u

nder

take

n by

a p

odia

tris

t

• P

assi

ve w

arm

ing

of le

gs im

prov

es

perf

usio

n an

d m

ay p

reve

nt a

rter

ial u

lcer

s

(e.g

. war

m s

ocks

, rug

s, e

nviro

nmen

t)

• A

ddre

ss p

sych

osoc

ial c

once

rns

with

a

mul

ti-di

scip

linar

y ca

re te

am

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

Ste

ed D

L et

al.

Gui

delin

es fo

r the

trea

tmen

t of d

iabe

tic u

lcer

s.

Wou

nd R

epai

r an

d R

egen

erat

ion

2006

. 14

(6):6

80-6

92

Ste

ed D

L et

al.

Gui

delin

es fo

r the

pre

vent

ion

of d

iabe

tic u

lcer

s.

Wou

nd R

epai

r an

d R

egen

erat

ion

2008

. 16

(2):1

69-1

74

Nat

iona

l Evi

denc

e-B

ased

Gui

delin

e on

Pre

vent

ion,

Iden

tifica

tion

and

Man

agem

ent o

f Foo

t Com

plic

atio

ns in

Dia

bete

s. M

elbo

urne

A

ustr

alia

: NH

MR

C 2

011

Sco

ttis

h In

terc

olle

giat

e G

uide

lines

Net

wor

k (S

IGN

) Man

agem

ent

of d

iab

etes

. A n

atio

nal c

linic

al g

uide

line.

Edi

nbur

gh, S

cotla

nd:

SIG

N 2

010

Reg

iste

red

Nur

ses’

Ass

ocia

tion

of O

ntar

io (R

NA

O) A

sses

smen

t an

d M

anag

emen

t of F

oot U

lcer

s fo

r P

eop

le w

ith D

iab

etes

. To

ront

o: R

NA

O 2

005

McI

ntos

h A

et a

l. P

reve

ntio

n an

d M

anag

emen

t of F

oot P

rob

lem

s in

Ty

pe

2 D

iab

etes

. She

ffiel

d: U

nive

rsity

of S

heffi

eld

: NIC

E 20

03

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustr

alia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

au

Thi

s P

roje

ct is

fund

ed b

y th

e A

ustr

alia

n G

over

nmen

t D

epar

tmen

t of H

ealth

and

Ag

eing

und

er t

he E

nco

urag

ing

Bet

ter

Pra

ctic

e in

Ag

ed C

are

(EB

PA

C) p

rog

ram

.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Info

rmat

ion

for h

ealt

h p

rofe

ssio

nal

s

Dia

betic

Foo

t Ulc

ers

Dia

betic

Foo

t Ulc

ers

Ass

essm

ent

• A

sses

smen

t sho

uld

be u

nder

take

n by

trai

ned

heal

th p

ract

ition

ers

• M

easu

rem

ent o

f Ank

le B

rach

ial P

ress

ure

Inde

x (A

BP

I) is

ess

entia

l. A

n A

BP

I of <

0.9

indi

cate

s ar

teria

l dis

ease

and

an

AB

PI >

1.2

requ

ires

furt

her i

nves

tigat

ion

• N

euro

path

y an

d lo

ss o

f sen

satio

n ca

n be

de

term

ined

by

mon

ofila

men

t tes

ting

in

com

bina

tion

with

clin

ical

ass

essm

ent

• A

sses

s ris

k fa

ctor

s (n

euro

path

y, P

AD

, foo

t de

form

ity) a

nd c

lass

ify fo

ot u

lcer

ris

k as

:

-lo

w:

no r

isk

fact

ors

or h

isto

ry o

f foo

t ulc

er/

ampu

tatio

n;

-in

term

edia

te:

one

risk

fact

or a

nd n

o hi

stor

y of

foot

ulc

er/a

mpu

tatio

n; o

r

-hi

gh:

2 or

mor

e ris

k fa

ctor

s an

d/o

r his

tory

of

foot

ulc

er/a

mpu

tatio

n

• R

efer

to a

spe

cial

ist w

hen

ther

e is

: -un

cert

aint

y in

dia

gnos

is -a

low

or h

igh

AB

PI

-ne

ed fo

r rev

ascu

laris

atio

n -no

pro

gres

s in

epi

thel

ialis

atio

n w

ithin

2 w

eeks

of

deb

ridem

ent a

nd c

omm

enci

ng o

ff-lo

adin

g -si

gns

of in

fect

ion

or in

flam

mat

ion

-th

e w

ound

can

be

prob

ed to

bon

e -w

ound

det

erio

ratio

n or

new

ulc

erat

ion

• R

egul

arly

doc

umen

t wou

nd c

hara

cter

istic

s an

d pr

ogre

ss in

hea

ling

Man

agem

ent

• In

volv

e a

mul

ti-di

scip

linar

y te

am w

ith G

P, n

urse

, po

diat

rist,

orth

otis

t, en

docr

inol

ogis

t. C

onsi

der

rem

ote

expe

rt a

dvic

e w

ith d

igita

l im

agin

g fo

r pe

ople

livi

ng in

rem

ote

area

s

• O

ffloa

ding

of p

ress

ure

poin

ts is

nec

essa

ry e

.g.

-cr

utch

es, w

alke

rs o

r whe

elch

airs

-cu

stom

sho

es, m

odifi

catio

ns o

r ins

erts

-cu

stom

relie

f ort

hotic

wal

kers

-fo

refo

ot a

nd h

eel r

elie

f sho

es -to

tal c

onta

ct c

asts

• Fa

cilit

ate

oxyg

enat

ion

of w

ound

env

ironm

ent -

av

oid

dehy

drat

ion,

sm

okin

g, c

old,

str

ess,

pai

n

• O

ptim

ise

gluc

ose

cont

rol

• Irr

igat

e ul

cer w

ith a

neu

tral

, non

-tox

ic s

olut

ion,

an

d cl

eans

e w

ith m

inim

al tr

aum

a

Dia

bet

ic f

oot

ulc

ers

are

usu

ally

on t

he

sole

of

the

foot

or

over

pre

ssure

poi

nts

. They

are

fre

quen

tly

surr

ounded b

y dry

, thin

and

/or

callo

use

d s

kin.

• R

emov

e ne

crot

ic a

nd d

evita

lised

tiss

ue,

unle

ss re

vasc

ular

isat

ion

is n

eces

sary

• D

ebrid

emen

t sho

uld

only

be

unde

rtak

en b

y tr

aine

d he

alth

pro

fess

iona

ls

• M

aint

ain

a m

oist

env

ironm

ent,

exce

pt w

hen

dry

gang

rene

or e

scha

r is

pres

ent

• To

pica

l ant

imic

robi

al d

ress

ings

may

ben

efit

chro

nica

lly o

r hea

vily

col

onis

ed w

ound

s

• R

e-ev

alua

te tr

eatm

ent i

f the

ulc

er s

ize

fails

to

redu

ce b

y 40

% a

fter 4

wee

ks o

f the

rapy

• A

dditi

onal

ther

apy

may

hel

p cl

ient

s, e

.g.:

-to

pica

l neg

ativ

e pr

essu

re th

erap

y

-cu

lture

d sk

in e

quiv

alen

ts

-hy

perb

aric

oxy

gen

ther

apy

Pre

venti

on

• A

ll in

divi

dual

s at

ris

k (i.

e. P

AD

, neu

ropa

thy,

ca

llus,

foot

def

orm

ity, p

revi

ous

ulce

ratio

n,

ampu

tatio

n) n

eed

prot

ectiv

e fo

otw

ear

• En

sure

cor

rect

foot

car

e is

pra

ctis

ed,

incl

udin

g da

ily in

spec

tion

of fe

et

• A

trai

ned

heal

th p

rofe

ssio

nal s

houl

d un

dert

ake

a fo

ot e

xam

inat

ion:

-an

nual

ly in

thos

e at

low

ris

k

-3-

6 m

onth

ly in

thos

e at

inte

rmed

iate

or

hig

h ris

k

• O

ptim

ise

gluc

ose

cont

rol

• D

isco

urag

e in

divi

dual

s fro

m s

mok

ing

• En

cour

age

mai

nten

ance

of a

hea

lthy

wei

ght

• P

rovi

de a

foot

pro

tect

ion

prog

ram

for t

hose

at

inte

rmed

iate

or h

igh

risk

for f

oot u

lcer

atio

n

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

Aus

tral

ian

Wou

nd M

anag

emen

t Ass

ocia

tion.

Pan

Pac

ific

Clin

ical

P

ract

ice

Gui

del

ine

for

the

Pre

vent

ion

and

Man

agem

ent o

f P

ress

ure

Inju

ry. O

sbor

ne P

ark,

WA

: Cam

brid

ge M

edia

201

2

AA

WC

. Ass

ocia

tion

for

the

Ad

vanc

emen

t of W

ound

Car

e gu

idel

ine

of p

ress

ure

ulce

r gu

idel

ines

. Mal

vern

, PA

: AA

WC

201

0

Ste

chm

iller

et a

l. G

uide

lines

for t

he p

reve

ntio

n of

pre

ssur

e ul

cers

. W

ound

Rep

Reg

ener

atio

n 20

08. 1

6:15

1-68

RN

AO

. Ris

k as

sess

men

t and

pre

vent

ion

of p

ress

ure

ulce

rs.

(Rev

ised

). To

ront

o: R

NA

O 2

011

NIC

E. T

he u

se o

f pre

ssur

e-re

lievi

ng d

evic

es fo

r th

e p

reve

ntio

n of

p

ress

ure

ulce

rs in

prim

ary

and

seco

ndar

y ca

re. L

ondo

n: R

oyal

C

olle

ge o

f Nur

sing

200

4

Roy

al C

olle

ge o

f Nur

sing

. The

man

agem

ent o

f pre

ssur

e ul

cers

in

prim

ary

and

seco

ndar

y ca

re: A

clin

ical

pra

ctic

e gu

idel

ine.

Lon

don:

R

CN

& N

ICE

2005

Whi

tney

et a

l. G

uide

lines

for t

he tr

eatm

ent o

f pre

ssur

e ul

cers

. W

ound

Rep

Reg

ener

atio

n 20

06. 1

4:66

3-79

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustr

alia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

au

Thi

s P

roje

ct is

fund

ed b

y th

e A

ustr

alia

n G

over

nmen

t D

epar

tmen

t of H

ealth

and

Ag

eing

und

er t

he E

nco

urag

ing

Bet

ter

Pra

ctic

e in

Ag

ed C

are

(EB

PA

C) p

rog

ram

.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Info

rmat

ion

for h

ealt

h p

rofe

ssio

nal

s

Pre

ssur

e In

juri

es

Pre

ssur

e In

juri

esA

sses

smen

t

• A

ll cl

ient

s sh

ould

hav

e a

risk

asse

ssm

ent u

sing

a

valid

ated

tool

, pe

rfor

med

and

doc

umen

ted

: -on

adm

issi

on

-at

regu

lar i

nter

vals

ther

eafte

r

-fo

llow

ing

any

chan

ge in

hea

lth s

tatu

s

• A

sses

smen

t sho

uld

be d

one

by s

taff

with

tr

aini

ng a

nd e

xper

tise

in th

e ar

ea

• A

sses

s th

e sk

in o

f at r

isk

clie

nts

daily

•

Reg

ular

ly a

sses

s an

d do

cum

ent w

ound

ch

arac

teris

tics,

incl

udin

g: lo

catio

n, s

ize,

sta

ge,

sign

s of

infe

ctio

n, w

ound

bed

, und

erm

inin

g

• R

egul

arly

ass

ess

clie

nts

with

pre

ssur

e in

jurie

s fo

r pai

n w

ith a

val

idat

ed p

ain

asse

ssm

ent t

ool

Ris

k Fa

ctor

s

• Im

mob

ility

or re

duce

d ph

ysic

al m

obilit

y

• Lo

ss o

f sen

satio

n

• Im

paire

d co

gniti

on

• P

rese

nce

of c

onst

ant m

oist

ure

on s

kin

• P

oor n

utrit

ion

and

hydr

atio

n

• D

ry s

kin

• A

cute

or s

ever

e illn

ess

Man

agem

ent

• P

ress

ure-

relie

ving

sur

face

s an

d st

rate

gies

sho

uld

be in

pla

ce 2

4 ho

urs

per d

ay fo

r all

indi

vidu

als

with

pre

ssur

e in

jurie

s

• Av

oid

posi

tioni

ng in

divi

dual

s di

rect

ly o

n pr

essu

re

inju

ries

or b

ony

prom

inen

ces

• A

hig

h sp

ecifi

catio

n re

activ

e (c

onst

ant l

ow

pres

sure

) or a

ctiv

e (a

ltern

atin

g pr

essu

re) s

uppo

rt

surfa

ce s

houl

d be

use

d fo

r clie

nts

with

pre

ssur

e in

jurie

s

• If

ther

e is

no

prog

ress

in h

ealin

g, o

r a s

tage

3–4

in

jury

(or u

nsta

geab

le o

r dee

p tis

sue

inju

ry) i

s pr

esen

t use

an

alte

rnat

ing

pres

sure

, low

-air-

loss

, co

ntin

uous

low

pre

ssur

e sy

stem

or a

ir-flu

idis

ed

bed

• Li

mit

the

amou

nt o

f tim

e in

bed

with

the

head

of

bed

elev

ated

• Irr

igat

e th

e w

ound

with

a n

eutra

l, no

n-to

xic

solu

tion,

and

cle

anse

with

min

imal

trau

ma

• D

ebrid

e ne

crot

ic a

nd d

evita

lised

tiss

ue.

Deb

ridem

ent s

houl

d on

ly b

e pe

rform

ed b

y st

aff

with

trai

ning

and

exp

ertis

e.

• Th

e fo

llow

ing

inte

rven

tions

may

pro

mot

e he

alin

g in

com

bina

tion

with

regu

lar c

are:

-to

pica

l neg

ativ

e pr

essu

re th

erap

y

-el

ectro

ther

apy

-pu

lsed

ele

ctro

mag

netic

ther

apy

• P

rovi

de h

igh

prot

ein

nutr

ition

al s

uppl

emen

ts,

incl

udin

g ar

gini

ne s

uppl

emen

ts

Pre

venti

on

• A

ll cl

ient

s at

risk

sho

uld

have

a p

reve

ntiv

e m

anag

emen

t pla

n

• P

rovi

de a

hig

h sp

ecifi

catio

n re

activ

e su

ppor

t fo

am, o

r act

ive

supp

ort m

attre

ss, f

or c

lient

s fo

und

at ri

sk

• Av

oid

irrita

ting

subs

tanc

es o

n th

e sk

in a

nd

moi

stur

ise

dry

skin

• O

ff-lo

ad p

ress

ure

on h

eels

for c

lient

s at

risk

• Av

oid

vigo

rous

mas

sage

ove

r bon

y pr

omin

ence

s

• U

se p

illow

s an

d fo

am w

edge

s to

redu

ce

pres

sure

on

bony

pro

min

ence

s

• Av

oid

prol

onge

d si

tting

in a

bed

or c

hair

• Av

oid

foam

ring

s, d

onut

s, n

on-m

edic

al g

rade

sh

eeps

kin,

or fl

uid

fille

d ba

gs

• R

epos

ition

the

clie

nt a

s fre

quen

tly a

s re

quire

d,

cons

ider

ing

thei

r ris

k

• M

aint

ain

optim

al n

utrit

iona

l sta

tus

• Ed

ucat

e cl

ient

s an

d ca

rers

on

way

s to

m

inim

ise

risk

A p

ress

ure

inju

ry is

a

loca

lised in

jury

to

the

skin

and

/or

under

lyin

g

tiss

ue,

usu

ally

ove

r a

bon

y pro

min

ence

, as

a re

sult

of

pre

ssure

, or

pre

ssure

in

com

bin

atio

n w

ith s

hea

r an

d/o

r fr

icti

on

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

WU

WH

S. P

rinci

ple

s of

bes

t pra

ctic

e: M

inim

isin

g p

ain

at w

ound

d

ress

ing-

rela

ted

pro

ced

ures

. Lon

don:

ME

P L

td 2

004

Aus

tral

ian

Wou

nd M

anag

emen

t Ass

oc. S

tand

ard

s fo

r w

ound

m

anag

emen

t. 2n

d ed

. Osb

orne

Par

k, W

A: C

ambr

idge

Med

ia 2

010

JBI W

ound

Hea

ling

and

Man

agem

ent N

ode

Gro

up. C

hron

ic

wou

nd m

anag

emen

t. (J

BI)

Bes

t Pra

ctic

e: e

vid

ence

-bas

ed

info

rmat

ion

shee

ts fo

r he

alth

pro

fess

iona

ls 2

011

Aus

tral

ian

Wou

nd M

anag

emen

t Ass

oc. P

ositi

on D

ocum

ent:

Bac

teria

l im

pac

t on

wou

nd h

ealin

g: fr

om c

onta

min

atio

n to

in

fect

ion.

AW

MA

201

1

Hop

f H e

t al.

Gui

delin

es fo

r the

trea

tmen

t of a

rter

ial i

nsuf

ficie

ncy

ulce

rs. W

ound

Rep

air

and

Reg

ener

atio

n 20

06. 1

4(6

): 69

3-71

0

WU

WH

S. P

rinci

ple

s of

bes

t pra

ctic

e: W

ound

exu

dat

e an

d th

e ro

le

of d

ress

ings

. Lon

don:

ME

P L

td 2

007.

Med

ical

Ad

viso

ry S

ecre

taria

t. C

omm

unity

-bas

ed c

are

for c

hron

ic

wou

nd m

anag

emen

t: A

n ev

iden

ce-b

ased

ana

lysi

s. O

ntar

io H

ealth

Te

chno

logy

Ass

essm

ent S

erie

s 20

09.9

(18

)

Whi

tney

J e

t al.

Gui

delin

es fo

r the

trea

tmen

t of p

ress

ure

ulce

rs.

Wou

nd R

epai

r an

d R

egen

erat

ion

2006

.14

(6):6

63-6

79

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustr

alia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

au

Thi

s P

roje

ct is

fund

ed b

y th

e A

ustr

alia

n G

over

nmen

t D

epar

tmen

t of H

ealth

and

Ag

eing

und

er t

he E

nco

urag

ing

Bet

ter

Pra

ctic

e in

Ag

ed C

are

(EB

PA

C) p

rog

ram

.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Info

rmat

ion

for h

ealt

h p

rofe

ssio

nal

s

Wou

nd C

are

Wou

nd C

are

Ass

essm

ent

• W

ound

ass

essm

ent s

houl

d be

und

erta

ken

by

trai

ned,

exp

erie

nced

hea

lth p

ract

ition

ers

• A

sses

s an

d do

cum

ent:

-ph

ysic

al e

xam

inat

ion

-ps

ycho

logi

cal w

ell-b

eing

-nu

triti

onal

sta

tus

-pa

in (i

nclu

ding

use

of a

pai

n sc

ale)

-hi

stor

y of

pre

viou

s w

ound

s

-cu

rren

t wou

nd d

urat

ion,

site

, tre

atm

ents

-w

ound

cha

ract

eris

tics:

siz

e, s

hape

, dep

th,

tissu

e ty

pe, e

xuda

te, m

argi

n, s

urro

undi

ng

skin

, sig

ns o

f inf

ectio

n

• R

eass

ess

and

docu

men

t pro

gres

s in

he

alin

g re

gula

rly

• R

eass

ess

pain

at e

ach

wou

nd d

ress

ing

usin

g a

stan

dard

ized

ass

essm

ent t

ool

A m

oist

wou

nd

en

viro

nm

ent

enab

les

mig

rati

on o

f ti

ssue

repai

ring

cells

. Ext

rem

e

wet

ness

or

dry

ness

may

del

ay h

ealin

g.

• U

se a

topi

cal a

ntim

icro

bial

age

nt in

clie

nts

with

crit

ical

ly c

olon

ised

, loc

alis

ed o

r sp

read

ing

wou

nd in

fect

ion;

the

leng

th o

f tr

eatm

ent d

eter

min

ed b

y th

e re

spon

se

• A

moi

st w

ound

env

ironm

ent s

houl

d be

m

aint

aine

d fo

r opt

imal

hea

ling

• D

ress

ings

sho

uld

:

-m

aint

ain

a m

oist

wou

nd e

nviro

nmen

t

-m

anag

e w

ound

exu

date

and

pro

tect

the

peri-

ulce

r ski

n

-m

inim

ise

frict

ion,

she

ar, s

kin

irrita

tion

and

pres

sure

-be

non

-adh

eren

t to

redu

ce tr

aum

a

-be

cos

t effe

ctiv

e an

d ab

le to

be

chan

ged

once

/day

or l

ess

ofte

n w

here

pos

sibl

e

• P

rom

ote

oxyg

enat

ion

of w

ound

en

viro

nmen

t - a

void

col

d, d

ehyd

ratio

n,

smok

ing,

str

ess,

pai

n

• Im

plem

ent e

ffect

ive

pain

man

agem

ent

durin

g w

ound

dre

ssin

gs

• En

cour

age

optim

al le

vels

of n

utrit

ion

• P

rovi

de e

duca

tion

on w

ound

car

e

• R

efer

to a

spe

cial

ist i

f the

re is

:

-un

cert

aint

y in

dia

gnos

is

-de

terio

ratio

n or

failu

re to

pro

gres

s to

hea

l

-un

expe

cted

cha

nge

in le

vel o

r typ

e of

pa

in o

r exu

date

-si

gns

of in

fect

ion

or is

chae

mia

Man

agem

ent

• W

ound

man

agem

ent s

houl

d be

und

erta

ken

by

trai

ned,

exp

erie

nced

hea

lth p

ract

ition

ers

• M

ultid

isci

plin

ary

man

agem

ent p

rom

otes

he

alin

g an

d im

prov

ed o

utco

mes

• C

lean

se w

ound

s w

ith a

neu

tral

, non

-tox

ic

solu

tion

(e.g

. pot

able

tap

wat

er o

r nor

mal

sa

line)

, with

min

imal

trau

ma

• R

emov

e ne

crot

ic a

nd d

evita

lised

tiss

ue th

roug

h m

echa

nica

l, sh

arp,

aut

olyt

ic o

r bio

logi

cal

debr

idem

ent

• If

dry

gang

rene

or e

scha

r is

pres

ent,

do n

ot

debr

ide

until

art

eria

l flow

is re

-est

ablis

hed

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

WU

WH

S. P

rinci

ples

of b

est p

ract

ice:

Min

imis

ing

pai

n at

wou

nd

dre

ssin

g-re

late

d p

roce

dur

es. L

ondo

n: M

EP

Ltd

200

4

Aus

tral

ian

Wou

nd M

anag

emen

t Ass

ocia

tion.

Sta

ndar

ds

for

wou

nd

man

agem

ent.

2nd

ed. O

sbor

ne P

ark,

WA

: Cam

brid

ge M

edia

201

0

JBI W

ound

Hea

ling

and

Man

agem

ent N

ode

Gro

up. C

hron

ic

wou

nd m

anag

emen

t. (J

BI)

Bes

t Pra

ctic

e: e

vide

nce-

base

d in

form

atio

n sh

eets

for h

ealth

pro

fess

iona

ls 2

011

Aus

tral

ian

Wou

nd M

anag

emen

t Ass

ocia

tion.

Pos

ition

Doc

umen

t: B

acte

rial i

mp

act o

n w

ound

hea

ling:

from

con

tam

inat

ion

to

infe

ctio

n. A

WM

A 2

011

Hop

f H e

t al.

Gui

delin

es fo

r the

trea

tmen

t of a

rter

ial i

nsuf

ficie

ncy

ulce

rs. W

ound

Rep

air

and

Reg

ener

atio

n 20

06. 1

4(6

):693

-710

WU

WH

S. P

rinci

ples

of b

est p

ract

ice:

Wou

nd e

xud

ate

and

the

role

of

dre

ssin

gs. A

con

sens

us d

ocum

ent.

Lond

on: M

EP

Ltd

200

7.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustr

alia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

au

Thi

s P

roje

ct is

fund

ed b

y th

e A

ustr

alia

n G

over

nmen

t D

epar

tmen

t of H

ealth

and

Ag

eing

und

er t

he E

nco

urag

ing

Bet

ter

Pra

ctic

e in

Ag

ed C

are

(EB

PA

C) p

rog

ram

.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Info

rmat

ion

for h

ealt

h p

rofe

ssio

nal

s

Wou

nd A

sses

smen

tD

ocum

enta

tion

shou

ld p

rovi

de

enou

gh in

form

atio

n t

o:

• m

onito

r pro

gres

s in

wou

nd h

ealin

g

• ev

alua

te th

e ef

fect

iven

ess

of m

anag

emen

t

• gu

ide

man

agem

ent a

nd p

reve

ntio

n pl

ans

Wou

nd A

sses

smen

tW

hat

is a

wou

nd?

A w

ound

is a

n in

jury

to th

e sk

in o

r und

erly

ing

tissu

e th

at m

ay o

r may

not

invo

lve

a lo

ss o

f ski

n in

tegr

ity.

Phy

siol

ogic

al fu

nctio

n of

the

tissu

e is

impa

ired.

C

omm

on ty

pes

incl

ude

leg

ulce

rs, t

raum

atic

w

ound

s, p

ress

ure

inju

ries,

sur

gica

l, an

d bu

rns.

Phas

es o

f w

ound h

ealin

g

1.

Hae

mos

tasi

s (b

leed

ing

stop

s):

10

min

utes

2.

Infla

mm

atio

n (re

dnes

s, s

wel

ling)

: 3

days

3.

Pro

lifer

atio

n (n

ew ti

ssue

gro

wth

): 28

day

s

4.

Mat

urat

ion

(rega

inin

g no

rmal

func

tion)

:

-a

year

or m

ore

Fact

ors

pro

mot

ing

wou

nd h

ealin

g

• A

moi

st h

ealin

g en

viro

nmen

t

• A

dequ

ate

bloo

d su

pply

and

oxy

gena

tion

• S

tabl

e te

mpe

ratu

re

• G

ood

nutri

tion

and

hydr

atio

n

• Tr

eatm

ent o

f und

erly

ing

med

ical

con

ditio

ns

• Av

oidi

ng p

ress

ure,

she

ar, f

rictio

n, m

acer

atio

n

• Av

oidi

ng s

mok

ing

Wou

nd A

sses

smen

t

• Ev

alua

te a

nd d

ocum

ent t

he fo

llow

ing:

-C

ause

, site

, typ

e an

d cl

assi

ficat

ion

of w

ound

-D

epth

: sup

erfic

ial,

part

ial o

r ful

l thi

ckne

ss

-S

ize

: tra

ce a

nd c

alcu

late

are

a on

firs

t pr

esen

tatio

n, th

en o

nce/

mon

th

-W

oun

d e

dg

e: s

lopi

ng, p

unch

ed o

ut, r

aise

d,

rolle

d, u

nder

min

ing,

pur

ple,

cal

lous

ed

-W

oun

d b

ed: n

ecro

tic, s

loug

hy, i

nfec

ted,

gr

anul

atin

g, e

pith

elia

lisat

ion

-E

xud

ate

: ser

ous,

hae

mos

erou

s, p

urul

ent

-S

urro

und

ing

ski

n: o

edem

a, c

ellu

litis

, col

our,

ecze

ma,

mac

erat

ion,

cap

illary

refil

l tim

e

-A

ny s

igns

of i

nfec

tion

: hea

t, re

dnes

s,

swel

ling,

pai

n, o

dour

, del

ayed

hea

ling

-P

ain

: ass

ocia

ted

with

dis

ease

, tra

uma,

in

fect

ion,

wou

nd c

are

prac

tices

, pro

duct

s

-Q

ualit

y o

f life

An a

cute

wou

nd t

hat

has

not

hea

led a

fter

28 d

ays

nee

ds

inve

stig

atio

n

Is t

he

wou

nd h

ealin

g?

✔Ye

s, s

igns

of a

hea

ling

wo

und

:

-pi

nk o

r rud

dy re

d in

col

our

-sm

all t

o m

oder

ate

amou

nts

of c

lear

or

sero

us e

xuda

te

-w

ound

is d

ecre

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g in

siz

e

-su

rrou

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g sk

in is

war

m, p

ink

and

heal

thy

✘N

o, s

igns

of a

n un

heal

thy

wo

und

:

-m

alod

our

-gr

een,

yel

low

slo

ugh

or n

ecro

tic ti

ssue

-la

rge

amou

nts

of e

xuda

te

-in

crea

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size

or n

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se in

siz

e

-su

rrou

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g sk

in is

red,

hot

, sw

olle

n

-in

crea

sed

pain

-sy

stem

ic s

ympt

oms

of in

fect

ion

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

AW

MA

, Sta

ndar

ds

for

Wou

nd M

anag

emen

t. 2n

d ed

201

0, O

sbor

ne

Par

k, W

A: C

ambr

idge

Med

ia

Tran

s Ta

sman

Die

tetic

Wou

nd C

are

Gro

up, E

vid

ence

bas

ed p

ract

ice

guid

elin

e fo

r the

die

tetic

man

agem

ent o

f ad

ults

with

pre

ssur

e in

jurie

s.

Rev

iew

1: 2

011

Dor

ner B

et a

l., th

e N

atio

nal P

ress

ure

Ulc

er A

dvi

sory

Pan

el, T

he r

ole

of n

utrit

ion

in p

ress

ure

ulce

r p

reve

ntio

n an

d tr

eatm

ent,

2009

, NP

UA

P

AW

MA

, Pan

Pac

ific

Clin

ical

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ctic

e G

uid

elin

e fo

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e P

reve

ntio

n an

d M

anag

emen

t of P

ress

ure

Inju

ry 2

012,

Osb

orne

Par

k, W

A: C

ambr

idge

M

edia

LeB

lanc

K, B

aran

oski

S, S

kin

tear

s: s

tate

of t

he s

cien

ce: c

onse

nsus

st

atem

ents

for t

he p

reve

ntio

n, p

redi

ctio

n, a

sses

smen

t, an

d tr

eatm

ent

of s

kin

tear

s. A

dv

Ski

n W

ound

Car

e, 2

011.

24

(9S

):2-1

5

NH

MR

C. D

ieta

ry G

uid

elin

es fo

r A

ustr

alia

n A

dul

ts. 2

003

Can

berr

a:

Com

mon

wea

lth o

f Aus

tral

ia

Woo

dwar

d et

al.

(Eds

) Nut

ritio

n an

d W

ound

Hea

ling.

200

8 N

estle

H

ealth

care

Nut

ritio

n

Woo

dwar

d M

. Gui

del

ines

to e

ffect

ive

hyd

ratio

n in

age

d ca

re fa

cilit

ies.

20

07. w

ww

.hyd

raly

te.c

om

/pd

f/ag

ed_c

are_

bro

chu

re.p

df

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustr

alia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

au

Thi

s P

roje

ct is

fund

ed b

y th

e A

ustr

alia

n G

over

nmen

t D

epar

tmen

t of H

ealth

and

Ag

eing

und

er t

he E

nco

urag

ing

Bet

ter

Pra

ctic

e in

Ag

ed C

are

(EB

PA

C) p

rog

ram

.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Info

rmat

ion

for h

ealt

h p

rofe

ssio

nal

s

Nut

ritio

n an

d

Wou

nd H

ealin

g

Nut

ritio

n an

d

Wou

nd H

ealin

gG

ood n

utr

itio

n a

nd h

ydra

tion

is

esse

nti

al for

wou

nd h

ealin

g

• O

lder

adu

lts a

re m

ore

likel

y to

be

mal

nour

ishe

d

• A

wou

nd in

crea

ses

ener

gy a

nd n

utrie

nt n

eeds

• D

ehyd

rate

d sk

in is

less

ela

stic

, mor

e fra

gile

and

m

ore

likel

y to

bre

akdo

wn

Ass

essm

ent

• U

se a

val

idat

ed n

utrit

iona

l scr

een

for a

ll cl

ient

s w

ith, o

r at r

isk

for,

a w

ound

• R

isk

fact

ors

for p

oor n

utrit

ion

incl

ude:

-po

or d

entit

ion

or d

ifficu

lty s

wal

low

ing

-po

or m

obilit

y

-re

duce

d ap

petit

e an

d ta

ste

chan

ges

-co

nfus

ion,

pai

n an

d/o

r anx

iety

-en

viro

nmen

t not

con

duci

ve to

eat

ing

Sig

ns o

f poo

r nut

ritio

nal a

nd/o

r hyd

ratio

n st

atus

:

• U

nint

entio

nal w

eigh

t los

s

• P

oor a

ppet

ite

• N

ause

a or

vom

iting

for t

hree

day

s or

mor

e

• D

ry, f

ragi

le s

kin

• Lo

ss o

f ski

n in

tegr

ity o

r a n

ew w

ound

• D

eter

iora

tion

of a

n ex

istin

g w

ound

Man

agem

ent

• A

ddre

ss a

ny n

utrit

iona

l defi

cits

• P

rovi

de n

utrit

iona

l int

erve

ntio

ns to

ass

ist

heal

ing

of p

ress

ure

inju

ries,

whi

ch in

clud

e:

-ad

equa

te c

alor

ic in

take

-a

high

pro

tein

sup

plem

ent,

incl

udin

g ar

gini

ne

-m

ultiv

itam

in s

uppl

emen

ts in

thos

e w

ith

defic

its

Pre

venti

on

• P

rom

ote

optim

al n

utrit

iona

l sta

tus

• H

igh

prot

ein

supp

lem

ents

may

hel

p pr

even

t pr

essu

re in

jurie

s in

thos

e at

hig

h ris

k

• R

efer

thos

e at

nut

ritio

nal r

isk

to a

die

ticia

n

Way

s to

pro

mot

e go

od n

utr

itio

n

and h

ydra

tion

• En

cour

age

a he

alth

y, b

alan

ced

diet

incl

udin

g th

e 5

food

gro

ups:

bre

ad/g

rain

s; v

eget

able

s;

fruit;

dai

ry p

rodu

cts

and

prot

ein

• En

cour

age

6—8

glas

ses

of fl

uid

/day

• P

rovi

de a

ssis

tanc

e w

ith m

eals

if n

eede

d an

d al

low

suf

ficie

nt ti

me

• En

sure

goo

d or

al a

nd d

enta

l car

e

• P

ositi

on u

prig

ht fo

r eat

ing

/ dr

inki

ng

• P

rovi

de a

ple

asan

t mea

ltim

e en

viro

nmen

t

Whic

h n

utr

ients

are

impor

tant

for

wou

nd h

ealin

g?

Pro

tein

: G

ood

sour

ces

incl

ude

mea

t, fis

h,

dairy

pro

duct

s, le

gum

es, n

uts,

see

ds a

nd

grai

ns

Vita

min

C: G

ood

sour

ces

incl

ude

citr

us fr

uits

, be

rrie

s, c

apsi

cum

, kiw

ifrui

t, pa

rsle

y, b

rocc

oli,

rock

mel

on, c

aulifl

ower

, spi

nach

and

cab

bage

Vita

min

A: G

ood

sour

ces

incl

ude

liver

, sw

eet

pota

to, c

arro

ts, b

rocc

oli,

leaf

y ve

geta

bles

, egg

s

Zin

c: G

ood

sour

ces

incl

ude

mea

t, se

afoo

d,

poul

try,

dai

ry p

rodu

cts,

see

ds, w

hole

grai

ns


promoting


promoting


References:

AWMA, Standards for wound management. 2nd ed 2010, Osborne Park, WA: Cambridge Media


AWMA, Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury 2012, Osborne Park, WA: Cambridge Media


promoting



CRICOS No. 00213J

www.ihbi.qut.edu.auThis Project is funded by the Australian Government Department of Health and Ageing under the Encouraging Better Practice in Aged Care (EBPAC) program.


promoting


Information for clients, family and carers

Ways to help ensure good nutrition and hydration

• Eat a healthy, balanced diet including all the five food groups each day

• Vary your meals and eat small meals or snacks frequently

• Drink 6 to 8 glasses of fluid a day, e.g. water, juice, yoghurt, soup

• Keep fluids handy and accessible• Sit upright when eating or drinking• Ensure good dental hygiene• Talk to a health professional if you

have any concerns


promoting


References:


AWMA. Standards for wound management. 2nd ed. Osborne Park, WA: Cambridge Media 2010

JBI Wound Healing and Management Node Group. Chronic wound management. (JBI) Best Practice: 2011

AWMA. Bacterial impact on wound healing: from contamination to infection. AWMA 2011

Hopf H et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair and Regeneration 2006. 14(6): 693-710

WUWHS. Principles of best practice: Wound exudate and the role of dressings. London: MEP Ltd 2007.


promoting



CRICOS No. 00213J



promoting

Wound CareInformation for clients, family and carers


promoting


References:

AWMA. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Osborne Park, WA: Cambridge Media 2012


Stechmiller J et al. Guidelines for the prevention of pressure ulcers. Wound Repair and Regeneration 2008. 16(2): p. 151-168

RNAO. Risk assessment and prevention of pressure ulcers. (Revised). Toronto, ON: RNAO 2011

Whitney J et al. Guidelines for the treatment of pressure ulcers. Wound Repair and Regeneration 2006. 14(6): p. 663-679


promoting



CRICOS No. 00213J



promoting

Pressure InjuriesInformation for clients, family and carers

3.2.5 Brochures for Clients, Family and Carers

The resource package includes a wide range of brochures for health professionals as well as clients, family and carers. The brochures are framed to match the audience. For example the brochures for the health professionals can be used as a clinical reference tool whereas the brochures for clients, family and carers use simplified language to provide wound sufferers and their carers with information about their wounds and management of the wounds.

• Skin Care

• Skin Tears





• Wound Care



Samples of all brochures are included at the back of this booklet


promoting


References:



National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes. Melbourne Australia 2011

Registered Nurses’ Association of Ontario (RNAO) Assessment and Management of Foot Ulcers for People with Diabetes. Toronto: RNAO 2005

McIntosh A et al. Prevention and Management of Foot Problems in Type 2 Diabetes. Sheffield: University of Sheffield: NICE 2003

Helpful ContactsDiabetes Australia Phone (Infoline): 1300 136 588 www.diabetesaustralia.com.au

The Australasian Podiatry Council Phone: 03 94163111 www.apodc.com.au


promoting



CRICOS No. 00213J



promoting

Diabetic Foot UlcersInformation for clients, family and carers


promoting


References:

Hopf, H., et al., Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair and Regeneration, 2006. 14(6):693-710

National Clinical Guideline Centre, Lower limb peripheral arterial disease. Diagnosis and management. NICE Clinical Guideline 147 Methods, evidence and recommendations, 2012: London

Hopf H., et al., Guidelines for prevention of lower extremity arterial ulcers. Wound Repair and Regeneration, 2008. 16(2):175-188

RNAO, Assessment and management of foot ulcers for people with diabetes. 2005. Toronto:RNAO


promoting



CRICOS No. 00213J



promoting

Arterial Leg UlcersInformation for clients, family and carers

Caring for venous leg ulcers

• Compression bandaging is the best way to treat venous ulcers

• Your doctor or nurse needs to check the circulation in your leg before starting compression

• 60% of ulcers will heal in 12 weeks with adequate compression


promoting


References:

Royal College of Nursing (RCN), Clinical practice guidelines: The management of patients with venous leg ulcers.2006 London: RCN Institute, Centre for Evidence based Nursing, University of York.

Registered Nurses’ Association of Ontario (RNAO), Assessment and Management of Venous Leg Ulcers. March 2004 ed. RNAO 2004, Toronto, Ontario: RNAO.

Australian Wound Management Association (AWMA), Australian and New Zealand Clinical Practice Guidelines for Prevention and Management of Venous Leg Ulcers, 2011, AWMA: Barton. ACT.


promoting



CRICOS No. 00213J



promoting

Venous Leg UlcersInformation for clients, family and carers


promoting


promoting60 Musk Ave Kelvin Grove Qld 4059 Brisbane, Australia


CRICOS No. 00213J


References:

Ratliff C, Fletcher K, Skin Tears: A review of the evidence to support prevention and treatment. Ostomy Wound Management, 2007.53(3)

Carville K et al., STAR: A consensus for skin tear classification. Primary Intention, 2007. 15(1): 18–28

Joanna Briggs Institute, Topical skin care in aged care facilities. Best Practice, 2007. 11(3)

Best Practice Statement: Care of the Older Person’s Skin Wounds UK 2012, 2nd ed. http://www.woundsinternational.com/pdf/content_10608.pdf

What to do for a skin tear

• Wash your hands• Gently clean the wound with warm

clean water • Pat dry with a clean towel • If a skin flap is still attached, try to

replace it by gently rolling the skin back over the wound, do not cut the skin flap off

• Cover the wound with a clean, non-stick pad

• Use a stockinette instead of adhesive dressings or tapes

• Contact your health professional



promoting

Skin TearsInformation for clients, family and carers


promoting


References:

Care of the Older Person’s Skin. 2nd ed. 2012: Wounds UK.

Gray M et al.: Incontinence-associated dermatitis: Wound, Ostomy, Continence Nursing 2012, 39:61-74.

The Joanna Briggs Institute: Topical skin care in aged care facilities. Best Practice: 2007, 11:1-4.

AWMA, Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury 2012, Cambridge Media Osborne Park, WA.

Stechmiller J et al.: Guidelines for the prevention of pressure ulcers. Wound Repair Regeneration 2008, 16:151-68.

Hodgkinson B, et al. A systematic review of topical skin care in aged care facilities. J Clinical Nursing 2006, 16:129-136.


promoting



CRICOS No. 00213J



promoting

Skin CareInformation for clients, family and carers

How does skin change with age?

• decreased sensation• increased dryness• thinning of the skin• decreased Vitamin D synthesis• reduced ability to fight infection• decreased control of temperature• it takes longer for the skin to heal• reduced elasticity and strength

3

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

Car

e of

the

Old

er P

erso

n’s

Ski

n. 2

nd e

d. 2

012:

Wou

nds

UK

.

Gra

y M

et a

l.: In

cont

inen

ce-a

ssoc

iate

d de

rmat

itis:

Wou

nd, O

stom

y,

Con

tinen

ce N

ursi

ng 2

012,

39:

61-7

4.

The

Joan

na B

riggs

Inst

itute

: Top

ical

ski

n ca

re in

age

d ca

re fa

cilit

ies.

B

est P

ract

ice:

200

7, 1

1:1-

4.

AW

MA

, Pan

Pac

ific

Clin

ical

Pra

ctic

e G

uide

line

for t

he P

reve

ntio

n an

d M

anag

emen

t of P

ress

ure

Inju

ry 2

012,

Cam

brid

ge M

edia

Osb

orne

Par

k, W

A.

Ste

chm

iller J

et a

l.: G

uide

lines

for t

he p

reve

ntio

n of

pre

ssur

e ul

cers

. W

ound

Rep

air R

egen

erat

ion

2008

, 16:

151-

68.

Hod

gkin

son

B, e

t al.

A s

yste

mat

ic re

view

of t

opic

al s

kin

care

in a

ged

care

fa

cilit

ies.

J C

linic

al N

ursi

ng 2

006,

16:

129-

136.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustra

lia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

auT

his

Pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of

Hea

lth a

nd A

gein

g un

der

the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

C

are

(EB

PA

C) p

rogr

am.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Ski

n C

are

Info

rmat

ion

for c

lients

, fam

ily a

nd c

arer

s

How

doe

s sk

in

chan

ge w

ith a

ge?

• de

crea

sed

sens

atio

n•

incr

ease

d dr

ynes

s•

thin

ning

of t

he s

kin

• de

crea

sed

Vita

min

D s

ynth

esis

• re

duce

d ab

ility

to fi

ght i

nfec

tion

• de

crea

sed

cont

rol o

f tem

pera

ture

• it

take

s lo

nger

for t

he s

kin

to h

eal

• re

duce

d el

astic

ity a

nd s

treng

th

Ski

n C

are

Funct

ions

of t

he

skin

incl

ude:

• P

rote

ctio

n•

Pro

vidi

ng a

bar

rier t

o in

fect

ion

• S

ensa

tion

or fe

elin

g•

Tem

pera

ture

con

trol

• M

etab

olis

m o

f Vita

min

D•

Elim

inat

ion

of w

aste

Ris

k fa

ctor

s fo

r sk

in p

roble

ms

• P

oor g

ener

al h

ealth

•

Red

uced

abi

lity

to m

ove

arou

nd•

Poo

r nut

ritio

nal s

tatu

s•

Sm

okin

g an

d al

coho

l usa

ge

• A

dvan

ced

age

• In

cont

inen

ce•

Som

e m

edic

atio

ns

Chec

k yo

ur

skin

dai

ly for

:

• W

ound

s•

Ras

hes

• B

ruis

ing

• S

kin

chan

ges

The

skin

is t

he

larg

est

or

gan

of

the

bod

y

It is

est

imat

ed t

hat

70%

of

old

er a

dult

s hav

e sk

in

pro

ble

ms

Regula

r as

sess

men

t of

the

skin

is im

por

tant

Tip

s on

car

ing

for

your

skin

✔D

o

• Ea

t a n

utrit

ious

die

t •

Drin

k 6—

8 gl

asse

s of

flui

d ev

ery

day

• C

hang

e po

sitio

n fre

quen

tly

• W

ear l

oose

cot

ton

clot

hing

•

Moi

stur

ise

skin

twic

e da

ily

• P

at s

kin

dry.

Do

not r

ub

• U

se a

bsor

bent

, dis

posa

ble

inco

ntin

ence

pro

duct

s if

need

ed

• B

arrie

r cre

ams

and

films

can

prev

ent

dam

age

to th

e sk

in

✘D

on’

t

• D

o no

t use

pro

duct

s th

at ir

ritat

e sk

in

e.g.

per

fum

ed lo

tions

• D

o no

t use

soa

p.

Try

soap

-free

cle

anse

rs

• D

o no

t was

h ex

cess

ivel

y –

wat

er d

ries

the

skin

• D

o no

t rub

the

skin

ove

r bo

ny a

reas

•

Do

not u

se ta

pes

or a

dhes

ives

pr

even

t dam

age

to th

e sk

in

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustra

lia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

auT

his

Pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of

Hea

lth a

nd A

gein

g un

der

the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

C

are

(EB

PA

C) p

rogr

am.

Ref

eren

ces:

Rat

liff C

, Fle

tche

r K, S

kin

Tear

s: A

revi

ew o

f the

evi

denc

e to

sup

port

pr

even

tion

and

trea

tmen

t. O

stom

y W

ound

Man

agem

ent,

2007

.53

(3)

Car

ville

K e

t al.,

STA

R: A

con

sens

us fo

r ski

n te

ar c

lass

ifica

tion.

Prim

ary

Inte

ntio

n, 2

007.

15

(1):

18–2

8

Joan

na B

riggs

Inst

itute

, Top

ical

ski

n ca

re in

age

d ca

re fa

cilit

ies.

Bes

t P

ract

ice,

200

7. 1

1(3)

Bes

t Pra

ctic

e S

tate

men

t: C

are

of th

e O

lder

Per

son’

s S

kin

Wou

nds

UK

201

2,

2nd

ed.

http

://w

ww

.wou

ndsi

nter

natio

nal.c

om/p

df/c

onte

nt_1

0608

.pdf

What

to

do

for

a sk

in t

ear

• W

ash

your

han

ds•

Gen

tly c

lean

the

wou

nd w

ith w

arm

cl

ean

wat

er

• P

at d

ry w

ith a

cle

an to

wel

•

If a

skin

flap

is s

till a

ttach

ed, t

ry to

re

plac

e it

by g

ently

rollin

g th

e sk

in

back

ove

r the

wou

nd, d

o no

t cut

th

e sk

in fl

ap o

ff

• C

over

the

wou

nd w

ith a

cle

an,

non-

stic

k pa

d

• U

se a

sto

ckin

ette

inst

ead

of a

dhes

ive

dres

sing

s or

tape

s

• C

onta

ct y

our h

ealth

pro

fess

iona

l

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Ski

n Te

ars

Info

rmat

ion

for c

lients

, fam

ily a

nd c

arer

s

Ski

n Te

ars

What

is a

ski

n t

ear?

• A

ski

n te

ar is

a b

reak

in th

e ou

ter

laye

rs o

f the

ski

n •

It ca

n re

sult

in th

e ‘p

eelin

g ba

ck’

of th

e sk

in, o

r par

tial o

r tot

al lo

ss o

f th

e sk

in

How

do

skin

tea

rs o

ccur?

Mos

t ski

n te

ars

occu

r bec

ause

of:

• Fa

lls, a

ccid

ents

, kno

cks

and

bum

ps•

Rem

oval

of t

apes

and

adh

esiv

es

Ris

k fa

ctor

s fo

r sk

in t

ears

You

are

at ri

sk fo

r a s

kin

tear

if y

ou:

• ha

ve d

ry, f

ragi

le s

kin

• ha

ve m

emor

y or

sen

sory

impa

irmen

t

• ha

ve p

oor m

obilit

y

• ha

ve p

oor n

utrit

ion

and

hydr

atio

n

• ar

e ta

king

mul

tiple

med

icat

ions

How

to

pre

vent

skin

tea

rs

✔D

o

• D

rink

6 to

8 g

lass

es o

f flui

d da

ily

• Ea

t a b

alan

ced,

nut

ritio

us d

iet

•

Kee

p fin

gern

ails

and

to

enai

ls tr

imm

ed•

App

ly m

oist

uris

er tw

ice

daily

• W

ear l

ong

slee

ves,

long

pan

ts o

r kn

ee-h

igh

sock

s to

pro

tect

ski

n

• En

sure

ade

quat

e lig

htin

g

✘D

on’

t

• D

o no

t use

tape

s or

adh

esiv

es•

Do

not u

se s

oap

for b

athi

ng—

try

soap

fre

e pr

oduc

ts fo

r cle

ansi

ng

How

car

ers

can h

elp

pre

vent

skin

tea

rs

✔D

o

• U

se c

orre

ct li

fting

, pos

ition

ing

and

trans

fer t

echn

ique

s

• U

se c

autio

n w

hen

bath

ing

and

dres

sing

•

Kee

p fin

gern

ails

trim

med

• P

rote

ct fr

agile

ski

n e.

g. u

se li

mb

prot

ecto

rs o

r lon

g sl

eeve

s or

pan

ts

• P

ad o

r cus

hion

equ

ipm

ent a

nd

furn

iture

e.g

. whe

elch

airs

•

Use

pillo

ws

(sat

in o

r silk

cov

ers

help

re

duce

fric

tion

and

shea

r) to

pos

ition

pe

ople

who

are

less

mob

ile

• P

rovi

de a

wel

l-lit,

saf

e en

viro

nmen

t

✘D

on’

t

• D

o no

t wea

r rin

gs th

at m

ay s

nag

skin

• D

o no

t pul

l the

ski

n du

ring

cont

act.

Use

ass

istiv

e de

vice

s e.

g. s

lide

shee

ts

• D

o no

t use

tape

s or

adh

esiv

es

Ski

n t

ears

are

a c

omm

on

pro

ble

m a

ffec

ting

older

peo

ple

Car

ing

for

venou

s le

g ulc

ers

• C

ompr

essi

on b

anda

ging

is th

e be

st

way

to tr

eat v

enou

s ul

cers

• Yo

ur d

octo

r or n

urse

nee

ds to

che

ck

the

circ

ulat

ion

in y

our l

eg b

efor

e st

artin

g co

mpr

essi

on•

60%

of u

lcer

s w

ill he

al in

12

wee

ks

with

ade

quat

e co

mpr

essi

on

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

Roy

al C

olle

ge o

f Nur

sing

(RC

N),

Clin

ical

pra

ctic

e gu

idel

ines

: The

m

anag

emen

t of p

atie

nts

with

ven

ous

leg

ulce

rs.2

006

Lond

on: R

CN

In

stitu

te, C

entr

e fo

r Evi

denc

e ba

sed

Nur

sing

, Uni

vers

ity o

f Yor

k.

Reg

iste

red

Nur

ses’

Ass

ocia

tion

of O

ntar

io (R

NA

O),

Ass

essm

ent a

nd

Man

agem

ent o

f Ven

ous

Leg

Ulc

ers.

Mar

ch 2

004

ed. R

NA

O 2

004,

Tor

onto

, O

ntar

io: R

NA

O.

Aus

tral

ian

Wou

nd M

anag

emen

t Ass

ocia

tion

(AW

MA

), A

ustr

alia

n an

d N

ew

Zeal

and

Clin

ical

Pra

ctic

e G

uide

lines

for P

reve

ntio

n an

d M

anag

emen

t of

Veno

us L

eg U

lcer

s, 2

011,

AW

MA

: Bar

ton.

AC

T.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustra

lia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

auT

his

Pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of

Hea

lth a

nd A

gein

g un

der

the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

C

are

(EB

PA

C) p

rogr

am.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Veno

us L

eg U

lcer

sIn

form

atio

n fo

r clie

nts

, fam

ily a

nd c

arer

s

Veno

us L

eg U

lcer

sW

hat

is a

ven

ous

leg

ulc

er?

• Ve

nous

ulc

ers

are

the

mos

t com

mon

ty

pe o

f leg

ulc

er. T

hey

are

caus

ed a

s th

e re

sult

of d

amag

ed v

eins

•

Vein

s dr

ain

bloo

d fro

m th

e fe

et a

nd

low

er le

gs b

ack

to th

e he

art.

Dam

age

to th

ese

vein

s re

sults

in s

wol

len,

te

nder

legs

whi

ch m

ay fe

el d

ry a

nd

itchy

and

hav

e m

ottle

d br

own

stai

ning

. Th

ey u

sual

ly o

ccur

on

the

low

er th

ird

of th

e le

g. P

ain

is u

sual

ly re

lieve

d by

el

evat

ing

the

legs

abo

ve th

e he

art

Ris

k Fa

ctor

s

• Va

ricos

e ve

ins

• B

lood

clo

ts

• Fr

actu

res

or in

jurie

s•

Obe

sity

• S

ittin

g or

sta

ndin

g fo

r lon

g pe

riods

How

to

pre

vent

ve

nou

s le

g ulc

ers

✔D

o

• W

ear c

ompr

essi

on s

tock

ings

for l

ife to

re

duce

the

risk

of n

ew le

g ul

cers

• R

epla

ce y

our c

ompr

essi

on s

tock

ings

ev

ery

six

mon

ths

• R

emov

e al

l wrin

kles

from

sto

ckin

gs.

Wea

ring

rubb

er g

love

s m

ay h

elp

• W

alk

or e

xerc

ise

your

ank

les

and

calf

mus

cles

regu

larly

•

Elev

ate

legs

abo

ve h

eart

leve

l for

30

min

utes

at l

east

onc

e a

day

•

App

ly m

oist

uris

er to

kee

p sk

in in

go

od c

ondi

tion

• C

heck

you

r fee

t and

legs

dai

ly

✘D

on’

t

• D

o no

t cro

ss y

our l

egs

• D

o no

t wea

r wat

ches

or j

ewel

lery

th

at c

an d

amag

e th

e st

ocki

ng•

Do

not f

old

over

sto

ckin

gs

at th

e to

p

Com

pre

ssio

n

stoc

kings

/so

cks

•

Com

pres

sion

sto

ckin

gs s

houl

d be

m

easu

red

and

fitte

d by

a h

ealth

pr

ofes

sion

al

• S

tock

ings

usu

ally

may

be

take

n of

f at n

ight

but

reap

ply

first

thin

g in

th

e m

orni

ng

• S

tock

ings

sho

uld

feel

firm

but

not

tigh

t

• Th

ere

is a

wid

e ra

nge

of e

quip

men

t av

aila

ble

to h

elp

put o

n st

ocki

ngs

• R

emov

e co

mpr

essi

on s

tock

ings

im

med

iate

ly if

toes

bec

ome

purp

le

or b

lue,

if s

wel

ling

of y

our l

eg o

ccur

s ab

ove

or b

elow

the

stoc

king

s, o

r you

de

velo

p se

vere

pai

n. S

eek

advi

ce fr

om

your

hea

lth p

rofe

ssio

nal

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

Hop

f, H

., et

al.,

Gui

delin

es fo

r the

trea

tmen

t of a

rter

ial i

nsuf

ficie

ncy

ulce

rs.

Wou

nd R

epai

r and

Reg

ener

atio

n, 2

006.

14(

6):6

93-7

10

Nat

iona

l Clin

ical

Gui

delin

e C

entr

e, L

ower

lim

b pe

riphe

ral a

rter

ial d

isea

se.

Dia

gnos

is a

nd m

anag

emen

t. N

ICE

Clin

ical

Gui

delin

e 14

7 M

etho

ds,

evid

ence

and

reco

mm

enda

tions

, 201

2: L

ondo

n

Hop

f H.,

et a

l., G

uide

lines

for p

reve

ntio

n of

low

er e

xtre

mity

art

eria

l ulc

ers.

W

ound

Rep

air a

nd R

egen

erat

ion,

200

8. 1

6(2

):175

-188

RN

AO

, Ass

essm

ent a

nd m

anag

emen

t of f

oot u

lcer

s fo

r peo

ple

with

di

abet

es. 2

005.

Tor

onto

:RN

AO

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustra

lia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

auT

his

Pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of

Hea

lth a

nd A

gein

g un

der

the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

C

are

(EB

PA

C) p

rogr

am.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Art

eria

l Leg

Ulc

ers

Info

rmat

ion

for c

lients

, fam

ily a

nd c

arer

s

Art

eria

l Leg

Ulc

erW

hat

is a

n a

rter

ial l

eg u

lcer

?

• A

n ar

teria

l leg

ulc

er is

a s

ore

or b

reak

in

the

skin

as

a re

sult

of b

lock

ed o

r ha

rden

ed a

rterie

s •

Arte

ries

supp

ly b

lood

whi

ch c

arry

ox

ygen

and

nut

rient

s to

the

mus

cles

an

d sk

in o

f the

legs

and

feet

•

If ci

rcul

atio

n is

poo

r the

leg

is s

tarv

ed

of o

xyge

n an

d nu

trien

ts a

nd th

e sk

in is

m

ore

likel

y to

bre

ak d

own

• Th

ey u

sual

ly o

ccur

ove

r the

toes

, shi

n or

pre

ssur

e ar

eas

of th

e fe

et a

nd le

gs•

They

may

cau

se s

ever

e pa

in a

t re

st, w

hich

ofte

n in

crea

ses

with

leg

elev

atio

n or

wal

king

Ris

k Fa

ctor

s

• S

mok

ing

• H

igh

bloo

d pr

essu

re

• A

his

tory

of h

eart

dis

ease

•

Obe

sity

•

Rhe

umat

oid

arth

ritis

•

Dia

bete

s

• A

hig

h ch

oles

tero

l lev

el

How

are

they

man

aged

?

• C

onsu

lt a

heal

th p

rofe

ssio

nal w

ith

skills

in w

ound

man

agem

ent

• B

lood

sup

ply

and

heal

ing

may

be

impr

oved

by:

-ke

epin

g yo

ur fe

et a

nd le

gs w

arm

-ge

ntle

leg

and

ankl

e ex

erci

ses

• Fo

llow

you

r hea

lth p

rofe

ssio

nal’s

ad

vice

on

how

to m

anag

e pa

in

How

can

you

hel

p p

reve

nt

an a

rter

ial

leg

ulc

er?

✔D

o

• G

ently

exe

rcis

e to

incr

ease

blo

od fl

ow

• Ea

t a h

ealth

y di

et

• In

spec

t fee

t and

legs

dai

ly –

a

mirr

or m

ay h

elp

• Q

uit s

mok

ing

• C

ontro

l dia

bete

s•

Con

trol y

our c

hole

ster

ol a

nd b

lood

pr

essu

re le

vels

• M

aint

ain

an id

eal w

eigh

t•

Wea

r wel

l fitti

ng s

hoes

and

ort

hotic

s as

nec

essa

ry

• Av

oid

inju

ry. T

ake

care

to a

void

bu

mps

and

sha

rp c

orne

rs•

Ext

rem

e ca

re is

nee

ded

whe

n cu

tting

to

e na

ils—

pref

erab

ly a

sk a

pod

iatri

st

✘D

on’

t

• D

o no

t sit

or s

tand

in o

ne p

ositi

on

for a

long

tim

e or

cro

ss y

our l

egs

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

Ste

ed D

L et

al.

Gui

delin

es fo

r the

trea

tmen

t of d

iabe

tic u

lcer

s. W

ound

R

epai

r and

Reg

ener

atio

n 20

06. 1

4(6

):680

-692

Ste

ed D

L et

al.

Gui

delin

es fo

r the

pre

vent

ion

of d

iabe

tic u

lcer

s. W

ound

R

epai

r and

Reg

ener

atio

n 20

08. 1

6(2

):169

-174

Nat

iona

l Evi

denc

e-B

ased

Gui

delin

e on

Pre

vent

ion,

Iden

tifica

tion

and

Man

agem

ent o

f Foo

t Com

plic

atio

ns in

Dia

bete

s. M

elbo

urne

Aus

tral

ia 2

011

Reg

iste

red

Nur

ses’

Ass

ocia

tion

of O

ntar

io (R

NA

O) A

sses

smen

t and

M

anag

emen

t of F

oot U

lcer

s fo

r Peo

ple

with

Dia

bete

s. T

oron

to: R

NA

O

2005

McI

ntos

h A

et a

l. P

reve

ntio

n an

d M

anag

emen

t of F

oot P

robl

ems

in T

ype

2 D

iabe

tes.

She

ffiel

d: U

nive

rsity

of S

heffi

eld

: NIC

E 20

03

Hel

pfu

l Con

tact

sD

iabe

tes

Aus

tralia

P

hone

(Inf

olin

e): 1

300

136

588

ww

w.d

iab

etes

aust

ralia

.com

.au

The

Aus

trala

sian

Pod

iatr

y C

ounc

il P

hone

: 03

941

6311

1 w

ww

.ap

odc.

com

.au

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustra

lia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

auT

his

Pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of

Hea

lth a

nd A

gein

g un

der

the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

C

are

(EB

PA

C) p

rogr

am.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Dia

betic

Foo

t Ulc

ers

Info

rmat

ion

for c

lients

, fam

ily a

nd c

arer

s

Dia

betic

Foo

t Ulc

ers

✔D

o

• S

ee a

ski

lled

heal

th p

rofe

ssio

nal t

o in

spec

t fee

t at l

east

onc

e a

year

•

Insp

ect y

our f

eet a

nd to

es d

aily

•

Cut

nai

ls s

traig

ht a

cros

s •

Che

ck th

ere

are

no s

harp

or r

ough

ed

ges

in s

hoes

bef

ore

putti

ng th

em o

n•

Tell

your

hea

lth p

rofe

ssio

nal a

s so

on

as p

ossi

ble

if yo

u no

tice

red

area

s, a

bl

iste

r, cu

t, sc

ratc

h or

sor

e •

Was

h an

d dr

y yo

ur fe

et c

aref

ully,

es

peci

ally

bet

wee

n th

e to

es

• C

heck

the

tem

pera

ture

of t

he w

ater

be

fore

put

ting

your

feet

in!

• C

hang

e yo

ur s

ocks

dai

ly

• U

se a

moi

stur

iser

for d

ry s

kin

but

avoi

d m

oist

uris

ing

betw

een

the

toes

•

Mon

itor b

lood

sug

ar le

vels

regu

larly

. H

ealth

y bl

ood

suge

r lev

els

prom

ote

heal

ing

• Ea

t a h

ealth

y di

et

• S

top

smok

ing

Poo

rly

fitt

ing

shoe

s ar

e

the

mos

t fr

equen

t ca

use

of

dia

bet

ic f

oot

ulc

ers

✘D

on’

t

• D

o no

t wal

k in

door

s or

out

door

s w

ithou

t soc

ks a

nd s

hoes

•

Do

not u

se p

last

ers

to re

mov

e ca

lluse

s—se

e a

heal

th p

rofe

ssio

nal

• D

o no

t use

a h

eate

r or h

ot w

ater

bo

ttle

to w

arm

you

r fee

t•

Do

not w

ear s

hoes

and

soc

ks th

at

are

too

tight

or t

oo lo

ose

• D

o no

t wea

r soc

ks w

ith s

eam

s

What

is a

dia

bet

ic foo

t ulc

er?

• A

dia

betic

foot

ulc

er is

a s

ore

or

brok

en s

kin

area

, ofte

n on

the

botto

m

of th

e fo

ot o

r ove

r bon

y ar

eas

• Th

ey c

an o

ccur

from

inju

ry, p

ress

ure,

or

rubb

ing

of s

kin

(e.g

. fro

m s

hoes

)

• Th

ey m

ay w

orse

n be

caus

e of

lack

of

feel

ing

(neu

ropa

thy)

in y

our f

eet

• M

ost d

iabe

tic fo

ot u

lcer

s ca

n be

pr

even

ted

or h

eale

d qu

ickl

y if

they

are

pi

cked

up

in th

e ea

rly s

tage

s

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

AW

MA

. Pan

Pac

ific

Clin

ical

Pra

ctic

e G

uide

line

for t

he P

reve

ntio

n an

d M

anag

emen

t of P

ress

ure

Inju

ry. O

sbor

ne P

ark,

WA

: Cam

brid

ge M

edia

20

12

AA

WC

. Ass

ocia

tion

for t

he A

dvan

cem

ent o

f Wou

nd C

are

guid

elin

e of

pr

essu

re u

lcer

gui

delin

es. M

alve

rn, P

A: A

AW

C 2

010

Ste

chm

iller J

et a

l. G

uide

lines

for t

he p

reve

ntio

n of

pre

ssur

e ul

cers

. Wou

nd

Rep

air a

nd R

egen

erat

ion

2008

. 16

(2):

p. 1

51-1

68

RN

AO

. Ris

k as

sess

men

t and

pre

vent

ion

of p

ress

ure

ulce

rs. (

Rev

ised

). To

ront

o, O

N: R

NA

O 2

011

Whi

tney

J e

t al.

Gui

delin

es fo

r the

trea

tmen

t of p

ress

ure

ulce

rs. W

ound

R

epai

r and

Reg

ener

atio

n 20

06. 1

4(6

): p.

663

-679

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustra

lia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

auT

his

Pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of

Hea

lth a

nd A

gein

g un

der

the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

C

are

(EB

PA

C) p

rogr

am.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Pre

ssur

e In

juri

esIn

form

atio

n fo

r clie

nts

, fam

ily a

nd c

arer

s

Pre

ssur

e In

juri

esW

hat

is a

pre

ssure

inju

ry?

• A

pre

ssur

e in

jury

is a

n ar

ea o

f ski

n th

at

has

been

dam

aged

bec

ause

of:

-un

relie

ved

pres

sure

-fri

ctio

n or

she

ar

(e.g

. poo

rly fi

tting

sho

es)

-pr

esen

ce o

f con

stan

t moi

stur

e

• Th

ey c

omm

only

occ

ur o

n th

e he

els,

to

es o

r but

tock

s

Ris

k Fa

ctor

s

• R

educ

ed m

obilit

y

• Lo

ss o

f sen

satio

n or

feel

ing

•

Impa

ired

men

tal s

tate

•

Inco

ntin

ence

•

Poo

r nut

ritio

n •

Dry

ski

n

• A

cute

or s

ever

e illn

ess

Pre

ssure

inju

ries

are

al

so c

alle

d:

• P

ress

ure

ulce

rs o

r are

as

•

Pre

ssur

e so

res

or b

ed s

ores

• D

ecub

itus

ulce

rs (d

ecub

iti)

• P

ress

ure

necr

osis

• Is

chae

mic

ulc

ers

How

you

can

hel

p c

are

for

a pre

ssure

inju

ry

Man

y of

the

actio

ns li

sted

(nex

t pag

e)

to p

reve

nt p

ress

ure

inju

ries

will

als

o he

lp h

eal a

n ul

cer i

f pre

sent

, i.e

.

• R

elie

ve th

e pr

essu

re fr

om th

e in

jury

ar

ea e

.g. d

o no

t lie

on

that

are

a, d

o no

t rub

the

area

• O

btai

n ad

vice

from

you

r doc

tor o

r nu

rse

on s

peci

al e

quip

men

t whi

ch c

an

relie

ve th

e pr

essu

re

How

to

pre

vent

a pre

ssure

in

jury

✔D

o

• A

pply

moi

stur

iser

twic

e da

ily

•

Use

mild

, pH

neu

tral,

non-

irrita

nt s

kin

clea

nser

s an

d bo

dy p

rodu

cts

•

Pro

tect

ski

n ex

pose

d to

fric

tion

•

Che

ck y

our s

kin

regu

larly

and

see

k he

lp if

you

hav

e an

y so

re, r

ed,

blis

tere

d or

bro

ken

skin

•

Eat a

nut

ritio

us d

iet

• U

se p

illow

s an

d fo

am w

edge

s to

pr

otec

t bon

y pr

omin

ence

s•

Avoi

d he

el o

r sac

ral c

onta

ct w

ith

hard

sur

face

s

✘D

on’

t

• D

o no

t mas

sage

or r

ub th

e sk

in o

ver

bony

are

as (e

.g. h

ip b

ones

) •

Do

not s

it in

a c

hair

for l

ong

perio

ds

of ti

me—

chan

ge p

ositi

on re

gula

rly

• D

o no

t use

foam

ring

s, d

onut

s,

or fl

uid

filled

bag

s

• D

o no

t lea

ve th

e sk

in in

con

tact

with

m

oist

ure

for l

ong

perio

ds o

f tim

e

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

re

pla

ce c

linic

al ju

dgm

ent

Ref

eren

ces:

WU

WH

S. P

rinci

ples

of b

est p

ract

ice:

Min

imis

ing

pain

at w

ound

dre

ssin

g-re

late

d pr

oced

ures

. Lon

don:

MEP

Ltd

200

4

AW

MA

. Sta

ndar

ds fo

r wou

nd m

anag

emen

t. 2nd

ed.

Osb

orne

Par

k, W

A:

Cam

brid

ge M

edia

201

0

JBI W

ound

Hea

ling

and

Man

agem

ent N

ode

Gro

up. C

hron

ic w

ound

m

anag

emen

t. (J

BI)

Bes

t Pra

ctic

e: 2

011

AW

MA

. Bac

teria

l im

pact

on

wou

nd h

ealin

g: fr

om c

onta

min

atio

n to

in

fect

ion.

AW

MA

201

1

Hop

f H e

t al.

Gui

delin

es fo

r the

trea

tmen

t of a

rter

ial i

nsuf

ficie

ncy

ulce

rs.

Wou

nd R

epai

r and

Reg

ener

atio

n 20

06. 1

4(6

): 69

3-71

0

WU

WH

S. P

rinci

ples

of b

est p

ract

ice:

Wou

nd e

xuda

te a

nd th

e ro

le o

f dr

essi

ngs.

Lon

don:

MEP

Ltd

200

7.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

60 M

usk

Ave

K

elvi

n G

rove

Qld

405

9 B

risba

ne, A

ustra

lia

Pho

ne: +

61

7 31

38 6

000

or

Fax:

+61

7 3

138

6030

or

Emai

l: ih

bi@

qut.e

du.a

u Em

ail (

Wou

nd H

ealin

g): w

ound

serv

ice@

qut.e

du.a

u

CR

ICO

S N

o. 0

0213

J

ww

w.ih

bi.q

ut.e

du.

auT

his

Pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of

Hea

lth a

nd A

gein

g un

der

the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

C

are

(EB

PA

C) p

rogr

am.

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

Wou

nd C

are

Info

rmat

ion

for c

lients

, fam

ily a

nd c

arer

s

Wou

nd C

are

What

is a

wou

nd?

• A

wou

nd is

an

inju

ry to

the

skin

or

unde

rlyin

g tis

sue.

The

nor

mal

func

tion

of th

e tis

sue

is d

amag

ed

• W

ound

s ca

n be

acc

iden

tal,

surg

ical

, or

occ

ur b

ecau

se o

f und

erly

ing

dise

ase

(e.g

. dia

bete

s)•

A w

ound

will

norm

ally

take

four

wee

ks

to h

eal i

n ol

der a

dults

• Th

e ce

lls a

nd m

olec

ules

whi

ch re

pair

wou

nds

need

moi

stur

e to

gro

w o

ver

the

wou

nd a

nd fo

rm n

ew ti

ssue

•

Res

earc

h ha

s fo

und

keep

ing

the

wou

nd c

over

ed w

ith a

dre

ssin

g

redu

ces

pain

and

low

ers

the

risk

of in

fect

ion

Wou

nds

whic

h a

re c

over

ed

an

d k

ept

moi

st h

eal m

ore

rapid

ly t

han

thos

e

expos

ed t

o ai

r

Hea

ling

a w

ound

✔D

o

• Ea

t a n

utrit

ious

die

t hig

h in

pro

tein

• If

you

suffe

r fro

m c

old

feet

or l

egs,

ke

ep y

our l

egs

war

m

• S

eek

advi

ce o

n pa

in m

anag

emen

t—

pain

can

rest

rict b

lood

flow

to th

e w

ound

• K

eep

dres

sing

s dr

y (d

o no

t wet

in

the

show

er, u

nles

s in

stru

cted

)

• U

se a

dre

ssin

g ty

pe w

hich

doe

s no

t st

ick

to th

e w

ound

• C

onsu

lt yo

ur h

ealth

pro

fess

iona

l ab

out h

ow o

ften

to c

hang

e th

e dr

essi

ngs.

Mos

t mod

ern

dres

sing

s re

quire

cha

ngin

g on

ce/d

ay o

r les

s to

pr

omot

e ra

pid

heal

ing

✘D

on’

t

• D

o no

t exp

ose

the

wou

nd to

air

or

the

sun

to ‘d

ry o

ut’

• D

o no

t sm

oke—

this

redu

ces

the

supp

ly o

f oxy

gen

to h

eal t

he w

ound

• D

o no

t use

tape

s an

d ad

hesi

ves

• D

o no

t was

h w

ound

s in

sea

wat

er

Con

tact

you

r hea

lth

pro

fess

ional

for

advi

ce o

n

trea

tmen

t, p

arti

cula

rly

if:

• Yo

u ha

ve d

iabe

tes

or a

rteria

l dis

ease

• Th

e w

ound

is n

ot h

ealin

g w

ithin

fo

ur w

eeks

•

Ther

e is

a c

hang

e or

incr

ease

in p

ain

• Th

e ar

ea a

roun

d th

e w

ound

is re

d, h

ot

to to

uch,

sw

olle

n an

d pa

infu

l. S

ome

redn

ess

and

swel

ling

is n

orm

al in

itally

, ho

wev

er, t

his

shou

ld re

solv

e w

ithin

a

wee

k•

The

wou

nd lo

oks

yello

w, p

ale

or

blac

k, h

as a

n of

fens

ive

smel

l, or

is

disc

harg

ing

gree

n flu

id o

r pus

heal

thy

skin

Cham

pions

for

Skin

Integrit

y

pro

moting

This

is a

guid

e on

ly a

nd d

oes

not

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promoting

3.3 Information links

3.3.1 Wound Care Organisations

Australian Wound Management Association and the AWMA State and Territory Associationswww.awma.com.au

Australasian Wound and Tissue Repair Society (AWTRS) www.awtrs.org

World Wide Wounds - The Electronic Journal of Wound Management Practice.www.worldwidewounds.com

Wounds Internationalwww.woundsinternational.com

European Wound Management Associationwww.ewma.org

National Pressure Ulcer Advisory Panel (U.S.)www.npuap.org

3.3.2 Evidence-based Guidelines

Australian Wound Management Associationwww.awma.com.au

European Wound Management Associationwww.ewma.org

Royal College of Nursing: UKwww.rcn.org.uk

National Guideline Clearinghousewww.guideline.gov

National Institute for Health and Clinical Excellence (NICE)www.nice.org.uk

Scottish Intercollegiate Guidelines Network (SIGN)www.sign.ac.uk

The Cochrane Collaboration / Librarywww.cochrane.org

Australasian Cochrane Centre - The Cochrane Librarywww.cochrane.org.au/library

National Health Medical Research Council: (NHMRC)www.nhmrc.gov.au/guidelines/health_guidelines.htm

The Joanna Briggs Institutehttp://www.joannabriggs.edu.au

JBI Connect: (Clinical Online Network of Evidence for Care and Therapeutics)www.jbiconnect.org

Registered Nurses Association of Ontario (RNAO)www.rnao.ca/bpg

3.3.3 Scholarships

Australian College of Nursing (ACN) offers several Australia Government sponsored programs, focused predominately on registered nursing staff in order to further education within aged care or the potential to attend conferences. www.acn.edu.au

3


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3.4 CSI Discussion Group Packages

Case studies provide trainees with a valuable tool to consolidate their knowledge gained through education sessions. A practical way of reviewing case studies is through the use of discussion groups.

• Discussion Group 1 – Implementing Evidence-Based Practice in Wound Management (Prevention and Management of Skin Tears)

• Discussion Group 2 – Implementing Evidence-Based Practice in Wound Management (Prevention and Management of Pressure Injuries)

• Discussion Group 3 - Implementing Evidence-Based Practice in Wound Management (Skin Care)

Discussion group packages listed below are included in this booklet. They can be photocopied directly from this booklet or alternatively can be printed from the relevant files included on the CSI resource files CD.

Implementing Evidence-Based practice in wound management

CSI Discussion group 3 Skin Care


promoting

This project is funded by the Australian Government Department of Health and

Ageing under the Encouraging Better Practice in Aged Care (EBPAC) program

Questions:

After reading the articles answer the following questions.

1. Identify strategies or risk factors that are similar in the articles on:

• Changes associated with ageing skin

• Factors affecting skin

• Prevention strategies

• Management strategies

2. How could you apply these strategies in your clinical practice?

3. Identify barriers and facilitators that may affect your ability to implement evidence based practice in your facility?

4. How could your facility help to change practice?

* Note: Product information included is an example only and does not represent an endorsement of any company or particular device.

Purpose: To provide evidence based information for promoting healthy skin in older adults.

Instructions: Read the following articles and then answer the questions.

Articles:

1. Hodgkinson, B. and Nay, R. (2005) Effectiveness of topical skin care provided in aged care facilities, International Journal Evidence Based Healthcare, vol. 3,pp. 65 – 101.

2. Joanna Briggs Institute (JBI) (2007) Topical Skin Care in Aged Care Facilities, Best Practice evidence based information sheet for health professionals, vol. 11, no. 3.

3. Lawton, S. (2007) Addressing the skin-care needs of the older person, British Journal of Community Nursing, vol. 12, no. 5, pp. 203 – 210.

4. Smith, J. (2007) To shower or not to shower – that is the question? ACQ Wire, August – September 2007, pp. 24 – 25.


CSI Discussion group 2 Prevention and Management of Pressure Injuries


promoting



Questions:


1. Identify strategies or risk factors that are similar in both articles on:

• Risk factors and causes of pressure injuries





4. How could your organisation help to change practice?

Purpose: To provide evidence based information for the prevention and management of pressure injuries in older adults.


Articles:

1. Kayser-Jones, J., Bear, R. and Sharpp, T. (2009) Dying with a Stage IV pressure ulcers, AJN, vol. 109, no. 1, pp. 40 – 48, 49.

2. Stechmiller, J., Cowan, L., Whitney, J., Phillips, M., Aslam, R., Barbul, A., Gottrup, F. et al (2008) Guidelines for the prevention of pressure ulcers, Wound Repair and Regeneration, vol. 16, pp. 151 – 168


CSI Discussion group 1 Prevention and Management of Skin Tears


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Questions:



• Risk factors and causes of skin tears




3. Identify barriers and facilitators that may affect your ability to implement evidence based practice?


Purpose: To provide evidence based information for the prevention and management of skin tears in older adults.


Articles:

1. Le Blanc, K. and Baranoski, S. (2009) Prevention and management of skin tears, Advances in Skin and Wound Care, vol. 22, pp. 325 – 332; quiz 333 – 334.

2. National Guideline Clearinghouse. Preventing pressure ulcers and skin tears. In: Evidence-based geriatric nursing protocols for best practice. Access from www.guideline.gov/summary/summary.aspx?doc_id=12262

3


CSI Discussion group 1 Prevention and Management of Skin Tears


promoting


Questions:



• Risk factors and causes of skin tears




3. Identify barriers and facilitators that may affect your ability to implement evidence based practice?


Purpose: To provide evidence based information for the prevention and management of skin tears in older adults.


Articles:

1. Le Blanc, K. and Baranoski, S. (2009) Prevention and management of skin tears, Advances in Skin and Wound Care, vol. 22, pp. 325 – 332; quiz 333 – 334.

2. National Guideline Clearinghouse. Preventing pressure ulcers and skin tears. In: Evidence-based geriatric nursing protocols for best practice. Access from www.guideline.gov/summary/summary.aspx?doc_id=12262


CSI Discussion group 2 Prevention and Management of Pressure Injuries


promoting


Questions:



• Risk factors and causes of pressure injuries






Purpose: To provide evidence based information for the prevention and management of pressure injuries in older adults.


Articles:

1. Kayser-Jones, J., Bear, R. and Sharpp, T. (2009) Dying with a Stage IV pressure ulcers, AJN, vol. 109, no. 1, pp. 40 – 48, 49.

2. Stechmiller, J., Cowan, L., Whitney, J., Phillips, M., Aslam, R., Barbul, A., Gottrup, F. et al (2008) Guidelines for the prevention of pressure ulcers, Wound Repair and Regeneration, vol. 16, pp. 151 – 168


CSI Discussion group 3 Skin Care


promoting


Questions:


1. Identify strategies or risk factors that are similar in the articles on:

• Changes associated with ageing skin

• Factors affecting skin





4. How could your facility help to change practice?

* Note: Product information included is an example only and does not represent an endorsement of any company or particular device.

Purpose: To provide evidence based information for promoting healthy skin in older adults.


Articles:

1. Hodgkinson, B. and Nay, R. (2005) Effectiveness of topical skin care provided in aged care facilities, International Journal Evidence Based Healthcare, vol. 3,pp. 65 – 101.

2. Joanna Briggs Institute (JBI) (2007) Topical Skin Care in Aged Care Facilities, Best Practice evidence based information sheet for health professionals, vol. 11, no. 3.

3. Lawton, S. (2007) Addressing the skin-care needs of the older person, British Journal of Community Nursing, vol. 12, no. 5, pp. 203 – 210.

4. Smith, J. (2007) To shower or not to shower – that is the question? ACQ Wire, August – September 2007, pp. 24 – 25.


promoting

10. Leave dressing on for 5 to 7 days or if 75% strike through

11. Remove dressing slowly in direction of arrows, moisten with water for easy release

12. If wound is healed leave open and moisturise

13. If wound has not healed apply a new soft silicone dressing and leaveon for 5 to 7 days

6. Apply a soft-silicone dressing (e.g. Mepilex Border™, Mepitel™ or Allevyn Gentle™) to wound overlapping the wound by at least 2cm

7. Draw arrows on the dressing to indicate the direction the dressing should be removed and date that dressing was applied

8. Apply a limb protector (e.g. Tubifast™) to prevent further injury

9. If you are not the RN notify the RN and document what you have done

3. Realign (if possible) any skin or flap using a moist cotton-tip

4. Assess and document the skin tear using the Skin Tear Assessment Tool

5. Assess the surrounding skin for swelling, discolouration or bruising. If flap colour is pale, dusky or darkened reassess in 24-48 hours or

at first dressing change

1. Control bleeding

2. Clean wound with warm normal saline, warm water or in shower. Pat dry

Skin Tear Management Guidelines

References:Ayello E, Sibbald G. Preventing pressure ulcers and skin tears. In: Capezuti E. et al. (eds) Evidence-based Geriatric Nursing Protocols for Best Practice. 3rd ed. New York: Springer Publishing Company 2008. http://www.guideline.gov/summary/summary.aspx?doc_id=12262

Carville K. et al. STAR: A Consensus for skin tear classification. Primary Intention 2007.. 15(1): 18–28

Payne R, Martin M. Defining and classifying skin tears: need for common language. Ostomy Wound Management 1993. 39(5): 16

Figure 1: Remove dressing in direction of arrow 5 to 7 days after application or if 75% strikethrough

Figure 2: Limb protector to prevent further trauma

Skin Tear Alert sticker for progress notes

SKIN TEAR ALERT

Resident name: Date Time

Location of skin tear:

Skin Tear Category: (tick box)

Category 1a Category 1b Category 2a Category 2b Category 3

Treatment:

Incident report Completed: (tick box) Yes No

Date of review Signature:

3.5 Skin Tear Management Package

Evidence suggests that older people are susceptible to skin tears10. As a result, the management of skin tears is an important function of the CSIs caring for older adults. To assist CSIs, a Skin Tear Management Package consisting of five tools was developed and is included in this booklet.

• Skin Tear – Assessment Tool

• Skin Tear – Prevention Guide

• Skin Tear – Alert Sticker for Progress Notes

• Skin Tear – Management Guidelines

• Skin Tear – Flow Chart (refer section 3.2.3)

The package can be photocopied directly from this booklet or alternatively can be printed from the relevant files included on the CSI resource files CD.

Skin Tear Prevention Guide Affix patient Label

DefinitionA skin tear is a traumatic wound as a result of friction alone or shearing and friction which separates the epidermis from the dermis (partial-thickness wound), or separates both the epidermis and dermis from underlying structures (full-thickness wound).

Risk factors for skin tears:


Presence of bruising or discoloured skin

Advanced age


Cognitive impairment/dementia

Dependency

Multiple medications

Impaired mobility

Dry skin/dehydration

Presence of friction, shearing, pressure


Disease processes (renal failure, heart disease, stroke)

Prevention Strategies:

Assess/recognize fragile, thin, vulnerable skin

Use soap-free bathing products to avoid drying the skin

Apply moisturiser to the skin twice daily

Use proper lifting, positioning and transfer techniques

Use caution when bathing and dressing

Avoid wearing rings that may snag the skin

Keep fingernails trimmed

Avoid direct contact that will pull the skin. Use assistive devices such as slide sheets

Protect fragile skin – use limb protectors and/or use clothing that has long sleeves or pants

Consider padding or cushioning equipment and furniture. For example, bed rails and wheelchairs to reduce risk of injury

Use pillows (satin or silk covers help to reduce to the risk of friction and shear) to position people who are less mobile or restricted to bed or chairs

Avoid using tapes or adhesives. If dressings or tapes are required, use paper tapes or soft silicone dressings to avoid tearing the skin upon removal

Provide a safe environment

Optimise nutrition and hydration

References:Ayello E, Sibbald G. Preventing pressure ulcers and skin tears. In: Capezuti E. et al. (eds) Evidence-based Geriatric Nursing Protocols for Best Practice. 3rd ed. New York: Springer Publishing Company 2008. www.guideline.gov/summary/summary.aspx?doc_id=12262

Carville K. et al. STAR: A Consensus for skin tear classification. Primary Intention 2007. 15(1): 18–28

Payne R. Martin M. Defining and classifying skin tears: need for common language. Ostomy Wound Management 1993. 39(5): 16


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Skin Tear Assessment Tool Affix patient Label

Date

Location of Skin Tear:


Category 1a

Category 1b – check within 24-48hrs

Category 2a


Category 3



Category 2aA skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened.

Category 2bA skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened.


Week 1Date Treatment Date For Next

Dressing ChangeInitials







If skin tear not healed within four weeks refer for specialist assessment

Note: Dressings should stay insitu for 5-7 days or unless strikethrough 75%

3

Skin Tear Assessment Tool Affix patient Label

Date

Location of Skin Tear:


Category 1a


Category 2a


Category 3














If skin tear not healed within four weeks refer for specialist assessment Note: Dressings should stay insitu for 5-7 days or unless strikethrough 75%

Skin Tear Prevention Guide Affix patient Label

DefinitionA skin tear is a traumatic wound as a result of friction alone or shearing and friction which separates the epidermis from the dermis (partial-thickness wound), or separates both the epidermis and dermis from underlying structures (full-thickness wound).

Risk factors for skin tears:


Presence of bruising or discoloured skin

Advanced age


Cognitive impairment/dementia

Dependency

Multiple medications

Impaired mobility

Dry skin/dehydration

Presence of friction, shearing, pressure


Disease processes (renal failure, heart disease, stroke)

Prevention Strategies:

Assess/recognize fragile, thin, vulnerable skin

Use soap-free bathing products to avoid drying the skin

Apply moisturiser to the skin twice daily

Use proper lifting, positioning and transfer techniques

Use caution when bathing and dressing

Avoid wearing rings that may snag the skin

Keep fingernails trimmed

Avoid direct contact that will pull the skin. Use assistive devices such as slide sheets

Protect fragile skin – use limb protectors and/or use clothing that has long sleeves or pants

Consider padding or cushioning equipment and furniture. For example, bed rails and wheelchairs to reduce risk of injury

Use pillows (satin or silk covers help to reduce to the risk of friction and shear) to position people who are less mobile or restricted to bed or chairs

Avoid using tapes or adhesives. If dressings or tapes are required, use paper tapes or soft silicone dressings to avoid tearing the skin upon removal

Provide a safe environment

Optimise nutrition and hydration

References:Ayello E, Sibbald G. Preventing pressure ulcers and skin tears. In: Capezuti E. et al. (eds) Evidence-based Geriatric Nursing Protocols for Best Practice. 3rd ed. New York: Springer Publishing Company 2008. www.guideline.gov/summary/summary.aspx?doc_id=12262

Carville K. et al. STAR: A Consensus for skin tear classification. Primary Intention 2007. 15(1): 18–28

Payne R. Martin M. Defining and classifying skin tears: need for common language. Ostomy Wound Management 1993. 39(5): 16


promoting

Skin Tear Alert sticker for progress notes

SKIN TEAR ALERT

Resident name: Date Time

Location of skin tear:


Category 1a Category 1b Category 2a Category 2b Category 3

Treatment:

Incident report Completed: (tick box) Yes No

Date of review Signature:


promoting

10. Leave dressing on for 5 to 7 days or if 75% strike through

11. Remove dressing slowly in direction of arrows, moisten with water for easy release

12. If wound is healed leave open and moisturise

13. If wound has not healed apply a new soft silicone dressing and leaveon for 5 to 7 days

6. Apply a soft-silicone dressing (e.g. Mepilex Border™, Mepitel™ or Allevyn Gentle™) to wound overlapping the wound by at least 2cm

7. Draw arrows on the dressing to indicate the direction the dressing should be removed and date that dressing was applied

8. Apply a limb protector (e.g. Tubifast™) to prevent further injury

9. If you are not the RN notify the RN and document what you have done

3. Realign (if possible) any skin or flap using a moist cotton-tip

4. Assess and document the skin tear using the Skin Tear Assessment Tool

5. Assess the surrounding skin for swelling, discolouration or bruising. If flap colour is pale, dusky or darkened reassess in 24-48 hours or

at first dressing change

1. Control bleeding

2. Clean wound with warm normal saline, warm water or in shower. Pat dry

Skin Tear Management Guidelines

References:Ayello E, Sibbald G. Preventing pressure ulcers and skin tears. In: Capezuti E. et al. (eds) Evidence-based Geriatric Nursing Protocols for Best Practice. 3rd ed. New York: Springer Publishing Company 2008. http://www.guideline.gov/summary/summary.aspx?doc_id=12262

Carville K. et al. STAR: A Consensus for skin tear classification. Primary Intention 2007.. 15(1): 18–28

Payne R, Martin M. Defining and classifying skin tears: need for common language. Ostomy Wound Management 1993. 39(5): 16

Figure 1: Remove dressing in direction of arrow 5 to 7 days after application or if 75% strikethrough

Figure 2: Limb protector to prevent further trauma


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4 Data Collection Tool4.1 Skin Integrity Survey

What is the purpose of a Skin Integrity Survey?

Clinical surveys and feedback is one way in which we can continually review practices in order to improve services, so that clients receive the best possible care.

Following is an example of a skin integrity survey form that may be useful within your organisation.

It is important to relay results obtained from doing a skin integrity survey back to other staff within the organisation.

• Skin Integrity Survey form

• Skin Integrity Survey Data Collection Training Guide (refer to the Powerpoint presentation included on the CSI resource files CD)

The following skin integrity data collection tool are included in the booklet. They can be photocopied directly from this booklet or alternatively can be printed from the relevant files included on the CSI resource files CD.

The CD also includes a PowerPoint Survey Data Collection Training Guide.

4

Skin Integrity Survey Form

List all wounds detected on examination Wound type

Wound present

Left Right List wound type (e.g. venous or arterial leg ulcer, diabetic foot ulcer, pressure injury, skin tear), category/stage of wound and location of wound e.g. Category 2a skin tear outer aspect of R calf

Head Arm Hip/iliac crest Sacrum/buttocks Back Leg Foot/toes Other Specify other

Total wounds present at examination:

1. There is evidence of:

Skin cancers

Chronic venous insufficiency

Peripheral vascular disease

Previous leg ulcers

Previous pressure injuries

Lower limb amputation

Previous skin tears

2. The following pressure reducing/relieving device(s) are present:

None

Speciality bed or chair

Comfort/adjunct devices

Replacement mattresses (static, dynamic)

Cushions/overlays (static/dynamic)

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. The following preventative interventions or strategies are in place:

None

Compression hosiery

Protective clothing

Specialised orthotic footwear

Foot and ankle exercises

Elevates limbs above heart level

Moisturising

Compression hosiery applicator device

Lighting

Turning schedule

Padded wheelchair foot plates, leg rests, bed rails

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Documentation within the last 5 days related to the management of any CURRENT wound(s):

None

Wound tracing

Wound assessment

Wound photography

Risk assessment

Dressings

Turning regimes

Compression bandaging (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pressure off-loading (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Referral (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Organisation protocol (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Investigations (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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Date / / MRN

Skin Integrity Classification System

STAR - Skin Tear Classification System Guidelines

1. Control bleeding and clean the wound according to protocol.2. Realign (if possible) any skin or flap.3. Assess degree of tissue loss and skin or flap colour using the STAR Classification System.4. Assess the surrounding skin condition for fragility, swelling, discolouration or bruising.5. Assess the person, their wound and their healing environment as per protocol.6. If skin or flap colour is pale, dusky or darkened reassess in 24-48 hours or at the first dressing change.

STAR classification System






Skin Tear Audit Research (STAR). Sliver Chain Nursing Association and School of Nursing and Midwifery, Curtin University of Technology. Revised 4/2/2010

Pressure Injury or Ulcer Staging

Stage 1Persistent redness in lightly pigmented skin. In darker skin the ulcer may appear with persistent red, blue or purple hues.

Stage 2Skin loss involving epidermis and/or dermis. The ulcer is superficial in appearance.

Stage 3Involves damage or necrosis of subcutaneous tissue that may extend down to but not through the underlying fascia.

Stage 4Full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often undermining or tunnelling.

Suspected Deep Tissue InjuryPurple or maroon localised area of discoloured or intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

UnstageableFull thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough and/or eschar in the bed.

GLoSSARyChronic venous insufficiency is a medical condition where, due to damaged or “incompetent” valves the veins cannot pump blood effectively back to the heart resulting in elevated ambulatory venous pressure (venous hypertension). Characteristics of chronic venous insufficiency may include oedema, skin staining, varicose veins, itchy legs and ulceration.

Peripheral Vascular Disease is caused by obstruction of the large arteries, especially in the extremities most commonly due to atherosclerosis. Characteristics of peripheral vascular disease include: claudication, rest pain, trophic changes, e.g. hair loss on the lower limb, thin shiny skin on the calves or feet, thickened toenails, purple colour of the limb in the dependent position, cool skin on palpation, mummified or dry and black toes, devitalized soft tissue with a wet or dry crust.

ReferencesCarville, K. et al. (2007). STAR: A consensus for skin tear classification. Primary Intention, 15(1), 18-28. • Dardik, A. et al. (2008) Guidelines for the prevention of lower extremity arterial ulcers, Wound Repair and Regeneration, 16, 175-188. • European Pressure Ulcer Advisory Panel and NPUAP. (2009) Prevention and treatment of pressure ulcers. Washington DC: NPUAP. • Robson, M. et al. (2006) Guidelines for the treatment of venous leg ulcers, Wound Rep Regen, 14, 649-662

EPUAP & NPUAP (2009)


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Skin Integrity Survey Form

List all wounds detected on examination Wound type

Wound present

Left Right List wound type (e.g. venous or arterial leg ulcer, diabetic foot ulcer, pressure injury, skin tear), category/stage of wound and location of wound e.g. Category 2a skin tear outer aspect of R calf

Head Arm Hip/iliac crest Sacrum/buttocks Back Leg Foot/toes Other Specify other

Total wounds present at examination:

1. There is evidence of:

Skin cancers

Chronic venous insufficiency

Peripheral vascular disease

Previous leg ulcers

Previous pressure injuries

Lower limb amputation

Previous skin tears

2. The following pressure reducing/relieving device(s) are present:

None

Speciality bed or chair

Comfort/adjunct devices

Replacement mattresses (static, dynamic)

Cushions/overlays (static/dynamic)

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. The following preventative interventions or strategies are in place:

None

Compression hosiery

Protective clothing

Specialised orthotic footwear

Foot and ankle exercises

Elevates limbs above heart level

Moisturising

Compression hosiery applicator device

Lighting

Turning schedule

Padded wheelchair foot plates, leg rests, bed rails

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Documentation within the last 5 days related to the management of any CURRENT wound(s):

None

Wound tracing

Wound assessment

Wound photography

Risk assessment

Dressings

Turning regimes

Compression bandaging (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pressure off-loading (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Referral (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Organisation protocol (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Investigations (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


promoting

Date / / MRN

Skin Integrity Classification System

STAR - Skin Tear Classification System Guidelines

1. Control bleeding and clean the wound according to protocol.2. Realign (if possible) any skin or flap.3. Assess degree of tissue loss and skin or flap colour using the STAR Classification System.4. Assess the surrounding skin condition for fragility, swelling, discolouration or bruising.5. Assess the person, their wound and their healing environment as per protocol.6. If skin or flap colour is pale, dusky or darkened reassess in 24-48 hours or at the first dressing change.

STAR classification System






Skin Tear Audit Research (STAR). Sliver Chain Nursing Association and School of Nursing and Midwifery, Curtin University of Technology. Revised 4/2/2010

Pressure Injury or Ulcer Staging

Stage 1Persistent redness in lightly pigmented skin. In darker skin the ulcer may appear with persistent red, blue or purple hues.

Stage 2Skin loss involving epidermis and/or dermis. The ulcer is superficial in appearance.

Stage 3Involves damage or necrosis of subcutaneous tissue that may extend down to but not through the underlying fascia.

Stage 4Full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often undermining or tunnelling.

Suspected Deep Tissue InjuryPurple or maroon localised area of discoloured or intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

UnstageableFull thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough and/or eschar in the bed.

GLoSSARyChronic venous insufficiency is a medical condition where, due to damaged or “incompetent” valves the veins cannot pump blood effectively back to the heart resulting in elevated ambulatory venous pressure (venous hypertension). Characteristics of chronic venous insufficiency may include oedema, skin staining, varicose veins, itchy legs and ulceration.

Peripheral Vascular Disease is caused by obstruction of the large arteries, especially in the extremities most commonly due to atherosclerosis. Characteristics of peripheral vascular disease include: claudication, rest pain, trophic changes, e.g. hair loss on the lower limb, thin shiny skin on the calves or feet, thickened toenails, purple colour of the limb in the dependent position, cool skin on palpation, mummified or dry and black toes, devitalized soft tissue with a wet or dry crust.

ReferencesCarville, K. et al. (2007). STAR: A consensus for skin tear classification. Primary Intention, 15(1), 18-28. • Dardik, A. et al. (2008) Guidelines for the prevention of lower extremity arterial ulcers, Wound Repair and Regeneration, 16, 175-188. • European Pressure Ulcer Advisory Panel and NPUAP. (2009) Prevention and treatment of pressure ulcers. Washington DC: NPUAP. • Robson, M. et al. (2006) Guidelines for the treatment of venous leg ulcers, Wound Rep Regen, 14, 649-662

EPUAP & NPUAP (2009)


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5

5 Meeting and Education Support Tools5.1 Meeting Support

Tools

As the multidisciplinary wound care networks and clinical linkages develop, it is likely that formal meetings will start to take place. It is important that such meetings are documented officially through the use of agendas, minutes and action lists. Meeting support tools have been included in this folder to assist all CSIs in the organisation and facilitation of meetings throughout their organisation. They can be adapted or modified to suit your organisation’s requirements.

• Agenda

• Minutes

• Action List

• Attendance Register

• Teleconference Guide

The following meeting support tools are included in the booklet. They can be photocopied directly from this booklet or alternatively can be printed from the relevant files included on the CSI resource files CD. MS Word versions of the first four files are also available on the CD and can be adapted to suit your organisation’s requirements.

Teleconference Guide Page 1 of 2

Teleconference Guide

Open communication channels between all interested parties will provide the

necessary support and momentum for the development of wound management

practices. If distance is a problem it may be worthwhile to look into teleconferencing.

Teleconferencing can be set up through your telephone service provider or other

teleconference service providers. You will be provided with a teleconference phone

number, a moderator pass code for you and a participant pass code for outside

callers.

This teleconferencing guide will provide the necessary information to support you

through the procedures of participating in a teleconference.

How to set up a teleconference?

Step 1: Dial the teleconference phone number provided by your teleconference

service provider several minutes before the scheduled meeting time and follow the

prompts.

Step 2: You will be prompted to enter the appropriate moderator pass code

provided.



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ATTENDA

NCE

REG

ISTER

Insert organ

isation logo

here

NAM

E OF MEETING: ___________________________________________________________________________________________________

DATE: __________________________

FULL NAM

E OCC

UPA

TION

ORG

ANISAT

ION

CONTA

CT DETAILS

SIGNAT

URE

Attendance Register

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Meetin

g Actio

n List

Insert organ

isation logo

here

Date

Activ

ity

Task

Actio

ner

Status

Action Plan

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MINUTES

Page 1 of 2

Insert organisation logo here

Title:

Date:

Time:

Place:

Attendees:

Apologies:

Guests:

Approval of previous meetings: Passed without amendment Proposer: Seconder: Passed with amendments Proposer: Seconder:

Amendments:

1. Business from previous meetings:

2. Monthly reviews: 2.1.

Discussion: Action: Actioned by: Deadline:

2.2. Discussion: Action: Actioned by: Deadline:

3. Items of business: 3.1.



Minutes


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AGENDA Insert organisation logo here

Title:

Date:

Time:

Place:

Attendees:

Apologies:

Guests:

Approval of previous meetings: Passed without amendment Proposer: Seconder: Passed with amendments Proposer: Seconder: Amendments:


2. Monthly reviews: 2.1. 2.2.

3. Items of business: 3.1. 3.2. 3.3.

4. Business not included on the agenda: 4.1.

5. Documents and papers: 5.1. 5.2.

6. Close of Meeting:

Time _____________

7. Next meeting: (Date, Time, Place)

Agenda


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AGENDA Insert organisation logo here

Title:

Date:

Time:

Place:

Attendees:

Apologies:

Guests:

Approval of previous meetings: Passed without amendment Proposer: Seconder: Passed with amendments Proposer: Seconder: Amendments:


2. Monthly reviews: 2.1. 2.2.

3. Items of business: 3.1. 3.2. 3.3.


5. Documents and papers: 5.1. 5.2.

6. Close of Meeting:

Time _____________


Agenda


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MINUTES

Page 1 of 2

Insert organisation logo here

Title:

Date:

Time:

Place:

Attendees:

Apologies:

Guests:

Approval of previous meetings: Passed without amendment Proposer: Seconder: Passed with amendments Proposer: Seconder:

Amendments:


2. Monthly reviews: 2.1.



3. Items of business: 3.1.



Minutes


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5. 5. Documents and papers: (e.g. Minutes from previous meeting) 5.1.

5.2.

6. Meeting closed: (Time)


Minutes (cont)


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Meetin

g Actio

n List

Insert organ

isation logo

here

Date

Activ

ity

Task

Actio

ner

Status

Action Plan

heal

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skin

Cham

pions

for

Skin

Integrit

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ATTENDA

NCE

REG

ISTER

Insert organ

isation logo

here

NAM

E OF MEETING: ___________________________________________________________________________________________________

DATE: __________________________

FULL NAM

E OCC

UPA

TION

ORG

ANISAT

ION

CONTA

CT DETAILS

SIGNAT

URE

Attendance Register

heal

thy

skin

Cham

pions

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Skin

Integrit

y

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Open communication channels between all interested parties will provide the

necessary support and momentum for the development of wound management

practices. If distance is a problem it may be worthwhile to look into teleconferencing.

Teleconferencing can be set up through your telephone service provider or other

teleconference service providers. You will be provided with a teleconference phone

number, a moderator pass code for you and a participant pass code for outside

callers.

This teleconferencing guide will provide the necessary information to support you

through the procedures of participating in a teleconference.

How to set up a teleconference?

Step 1: Dial the teleconference phone number provided by your teleconference

service provider several minutes before the scheduled meeting time and follow the

prompts.

Step 2: You will be prompted to enter the appropriate moderator pass code

provided.



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How to Participate? (A few suggested Do’s and Don’ts)

The audio quality of the teleconference is greatly improved if participants use

landlines instead of mobile telephones. Mobile phones are also much more likely

to be dropped than landlines.

If there is a lot of background noise in your location mute your line when not

speaking. Optus mute code is *6. Your teleconference service provider may use

a different code. This will mute your line and block out background noise. When

you are ready to speak press *6 to un-mute your line.

Please preface your comments during calls with your name so that those

listening know who is speaking.

Please remember to ask for the floor before speaking, and ensure not to speak

over any other person as this will make it difficult for others to understand you.

Please remember when speaking to sit in a close proximity to the speaker phone

and to speak clearly and at a moderate pace.

Teleconference Guide (cont)


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5.2 Education Support Tools

One of the key roles of the CSI is to enhance knowledge, skills and attitudes of staff towards skin integrity by contributing or facilitating educational in-services for staff.

The resource kit includes a range of education support tools designed to assist CSIs in the organisation and facilitation of education workshops throughout their organisation. They can be adapted or modified to suit your organisation’s requirements for future skin integrity and evidence-based practice training.

• Fact sheet – Evidence-based Practice

• Power point presentation slide (only available on the CD)

• Education session – Evaluation Form

• Education Session - Attendance Register

The following education support tools are included in the booklet. They can be photocopied directly from this booklet or alternatively can be printed from the relevant files included on the CSI resource files CD. MS Word versions of the education session files are also available on the CD and can be adapted to suit your organisation’s requirements.

5 ATTENDA

NCE

REG

ISTER

NAM

E OF ED

UCA

TION/TRA

INING SESSION: _________________________________________________________________________________

DATE: __________________________

FULL NAM

E OCC

UPA

TION

ORG

ANISAT

ION

CONTA

CT DETAILS

SIGNAT

URE

Education session - Attendance Register

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Education Session Evaluation Form Page 3 of 3

5. Were you happy with the registration process, and the information provided to you prior to the workshop? What could we have done better?

6. Would you recommend this workshop to others? Please give reasons.

7. Additional comments:

Thank you

Education session - Evaluation Form


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Fact Sheet - Evidence Based Practice


What is ‘Evidence Based Practice’? Evidence based practice has been described as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al. 19961).

Evidence based practice encompasses consideration of the best available research evidence, clinical expertise, context and patient preferences when making decisions on the provision of care.

The need for evidence to support patient care is not new. Florence Nightingale used evidence from patient morbidity statistics to make decisions about the care provided to injured soldiers. Today many factors have pushed the need for evidence based practice to the fore, including rising costs of health care and the need to improve the quality of health care outcomes for patients and communities.

What is ‘Best Evidence’? Best Evidence refers to a synthesis of results obtained from rigorous evaluation of research studies related to treatments, interventions, care practices or clinical problems.

Evidence may include results from different types of research studies, e.g. randomised controlled trials, case control studies, descriptive studies or qualitative studies.

When evaluating the evidence, consideration is given to:

• The strength of the evidence (i.e. the quality of the study and how well the study design reduces bias in results)

• The size of the effect (e.g. if a study finds one treatment is better than other, was there a large or small difference in the clinical outcomes?)

• Relevance of the results (i.e. are the results relevant to your patient population, context or the particular intervention of interest?) 2

Where is the evidence? The Champions for Skin Integrity project aims to provide pathways to assist all staff gain awareness of evidence, evidence based guidelines and how to implement evidence into practice. For assisting in finding evidence in wound management, access Module 8 ‘Finding Evidence’ in the Self Education DVD provided in this resource folder.

1Sackett et al. 1996. Evidence based medicine: What it is and what it isn’t. BMJ 312:71-72. 2Commonwealth of Australia NHMRC. 2000. How to use the evidence. NHMRC, AusInfo: Canberra.


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What is ‘Evidence Based Practice’? Evidence based practice has been described as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al. 19961).

Evidence based practice encompasses consideration of the best available research evidence, clinical expertise, context and patient preferences when making decisions on the provision of care.

The need for evidence to support patient care is not new. Florence Nightingale used evidence from patient morbidity statistics to make decisions about the care provided to injured soldiers. Today many factors have pushed the need for evidence based practice to the fore, including rising costs of health care and the need to improve the quality of health care outcomes for patients and communities.

What is ‘Best Evidence’? Best Evidence refers to a synthesis of results obtained from rigorous evaluation of research studies related to treatments, interventions, care practices or clinical problems.

Evidence may include results from different types of research studies, e.g. randomised controlled trials, case control studies, descriptive studies or qualitative studies.

When evaluating the evidence, consideration is given to:

• The strength of the evidence (i.e. the quality of the study and how well the study design reduces bias in results)

• The size of the effect (e.g. if a study finds one treatment is better than other, was there a large or small difference in the clinical outcomes?)

• Relevance of the results (i.e. are the results relevant to your patient population, context or the particular intervention of interest?) 2

Where is the evidence? The Champions for Skin Integrity project aims to provide pathways to assist all staff gain awareness of evidence, evidence based guidelines and how to implement evidence into practice. For assisting in finding evidence in wound management, access Module 8 ‘Finding Evidence’ in the Self Education DVD provided in this resource folder.

1Sackett et al. 1996. Evidence based medicine: What it is and what it isn’t. BMJ 312:71-72. 2Commonwealth of Australia NHMRC. 2000. How to use the evidence. NHMRC, AusInfo: Canberra.


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EDUCATION SESSION EVALUATION FORM


Participant Name: (Optional)

Organisation:

Job Title:

Date:

Venue:

Name of Workshop:

Using the rating scale below, please indicate the level of your agreement with the following statements about the workshop you have completed.

1 = Strongly disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree

1 2 3 4 5 na Additional Comments:

The workshop met my expectations

The workshop was relevant to my current position and duties

The facilitator communicated the course content effectively

The facilitator provided assistance at my level of need

The workshop materials were well organised, well written, and easy to follow

The workshop was well structured

The amount of information was sufficient

The pace of the program was appropriate for the workshop

There was sufficient opportunities provided for interaction and participation

The catering was sufficient



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1. What knowledge and/or skills did you gain from the workshop?

2. How would you apply what you have learnt in your workplace?

3. What part(s) of the workshop did you find most useful?

4. Were any topics still unclear? Which ones, and why? How could the workshop be improved?



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5. Were you happy with the registration process, and the information provided to you prior to the workshop? What could we have done better?

6. Would you recommend this workshop to others? Please give reasons.

7. Additional comments:

Thank you



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ATTENDA

NCE

REG

ISTER

NAM

E OF ED

UCA

TION/TRA

INING SESSION: _________________________________________________________________________________

DATE: __________________________

FULL NAM

E OCC

UPA

TION

ORG

ANISAT

ION

CONTA

CT DETAILS

SIGNAT

URE

Education session - Attendance Register

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6 References

1. Coyer F, Edwards H, Courtney M, Best Practice Community Care for Clients with Chronic Venous Leg Ulcers: National Institute for Clinical Studies (NICS) Report for Phase I Evidence Uptake Network, 2005, Queensland University of Technology: Brisbane.

2. Baker SR, Stacey MC: Epidemiology of chronic leg ulcers in Australia. Australian and New Zealand Journal of Surgery 1994, 64:258-61.

3. International Diabetic Foot Federation, International Consensus on the Diabetic Foot and Practical Guidelines on the Management and Prevention of the Diabetic Foot 2007. 2007, Amsterdam: International Working Group on the Diabetic Foot.

4. Briggs M, Closs SJ: The prevalence of leg ulceration: a review of the literature. EWMA Journal 2003, 3:14-20.

5. Carville K, Lewin G, Newall Net al.: STAR: A consensus for skin tear classification. Primary Intention 2007, 15:18-28.

6. Everett S, Powell T: Skin Tears - The underestimated wound. Primary Intention 1994, 2:11.

7. Bours G, Halfens R, Abu-Saad H, Grol R: Prevalence, prevention, and treatment of pressure ulcers: Descriptive study in 89 institutions in The Netherlands. Research in Nursing and Health 2002, 25:99-110.

8. Young J, Nikoletti S, McCaul K et al.: Risk factors associated with pressure ulcer development at a major Western Australian teaching hospital from 1998 to 2000: Secondary data analysis. WOUND CARE: Journal of Wound, Ostomy & Continence Nursing 2002, 29:234-241.

9. Anand S, Dean C, Nettleton R, Praburaj D: Health-related quality of life tools for venous-ulcerated patients. British Journal of Nursing 2003, 12:48-59.

10. Nelson EA, Bell-Syer SEM, Cullum NA: Compression for preventing recurrence of venous ulcers. Cochrane Database of Systematic Reviews 2000, 4:CD002303.

11. Edwards H, Courtney M, Finlayson K et al.: Chronic venous leg ulcers: effect of a community nursing intervention on pain and healing. Nursing Standard 2005, 19:47-54.

12. Walker N, Rodgers A, Birchall N, Norton R, MacMahon S: Leg ulcers in New Zealand: age at onset, recurrence and provision of care in an urban population. New Zealand Medical Journal 2002, 115:286-289.

13. McGuckin M, Waterman R, Brooks Jet al.: Validation of venous leg ulcer guidelines in the United States and United Kingdom. American Journal of Surgery 2002, 183:132-7.

14. Finlayson K, Edwards H, Courtney M: Factors associated with recurrence of venous leg ulcers. International Journal of Nursing Studies 2009, 46:1071-1078.

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