Rehabilitation Best Practice Standards Functional Standard Number: 2 Skin Care Effective Date: September 2005

Author(s): Developed by Rehab Amputee Best Practice Team Issuing Authority: Vancouver Island Health Authority Date last reviewed/revised: February 2006

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REHABILITATION STANDARD: SKIN CARE (Excluding

Burns)

This care standard outlines the rehabilitation process for individuals who present with the potential for or existing skin breakdown or wounds. Skin care is the responsibility of the individual, their supports, and the healthcare providers. Complex skin care issues may require a multidisciplinary team with a wide range of expertise. The goal is to restore or maintain intact healthy skin and promote wound healing. Criteria for Referral Individuals experiencing the following risk factors should be assessed by a healthcare provider:

� Limited Mobility � Impaired sensation � Incontinence � Age and reduced skin quality � Poor nutrition � Long term steroid use � Cognitive impairment � Visual impairment � Diabetes � Peripheral Vascular Disease

The healthcare provider must obtain informed consent from the individual prior to the initiation of any assessment and intervention. Screen Any healthcare provider can perform a basic skin care screen, which should include the following:

� Skin inspection � Assessment of health risk factors � Assessments of potential pressure areas.

The Braden Scale or SIRA would be standardized tools that could be used to assist with the screen.

If the interventions for skin care management exceed the healthcare provider’s expertise or knowledge, a referral for an assessment should be made at first contact and clearly documented.

Results of the screen including any recommendations will be documented in the individual’s chart.

Assessment An assessment is indicated when the individual presents with open wounds, multiple risk factors for skin breakdown, or when a more in-depth assessment is necessary. This assessment may involve nursing and a multidisciplinary team with expertise in skin care. This assessment will take into consideration all factors assessed in the screen and may involve a more comprehensive evaluation of the following factors:

� Medical conditions � Physical attributes � Mental Status � Cognitive/perceptual factors � Psychosocial issues

Residents of Vancouver Island Health Authority (VIHA) will have reasonable access to consistent, integrated, measurable, evidence based rehabilitation services. This will be achieved through the use of standards that describe the baseline for rehabilitation services that an individual can expect to receive in VIHA.

Rehabilitation Best Practice Standards Functional Standard Number: 2 Skin Care Effective Date: September 2005

Author(s): Developed by Rehab Amputee Best Practice Team Issuing Authority: Vancouver Island Health Authority Date last reviewed/revised: February 2006

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� Overall function (mobility, self-care etc.) Plan The multidisciplinary health care team members will collaborate with the individual and the family/caregiver to develop a plan to address the skin care issues. The plan will address:

� Maintenance of normal skin hydration � Nutritional information � Avoidance of pressure � Pressure reducing equipment and devices � Need for mobilization and position change � Wound care/healing

The expected outcome is that the individual’s skin integrity will be restored and/or maintained in a healthy, intact manner. Individuals and their families will have the information (education) and tools (equipment/devices) to prevent skin breakdown and take an active part in the care of their skin. Documentation The multidisciplinary healthcare team is responsible for documenting the results of skin care assessments, treatment plans and ongoing progress notes regarding the resolution/management of wounds or pressure areas. This documentation should be kept in a manner that is accessible to all members of the team using communication tools such as the cardex, care plan, ADL card, or information booklet. Digital photos may be used to track the progress of wound healing and this technology may aid in accessing specialists for consultation. Evaluation The indicators use to evaluate this standard include outcome indicators based on the individual’s goals and process indicators based on the effectiveness of the standard Individual outcome indicators could include:

� Number of reported pressure sores/difficult to heal wounds � Number of referrals to home care nursing for wound care � Satisfaction surveys � The individuals knowledge of skin care strategies � Decreased expenditures for dressing supplies

Process Indicators could include:

� Audit the use of standardized tools If any component of the treatment is to be delegated, the individual will be informed.