Bruising or Ecchymosis PowerPoint Presentation

Bruising or Ecchymosis PowerPoint Presentation

2015-09-28 85K 85 0 0


Skin Tear Prevention . Category I:. Skin tear WITHOUT tissue loss. Category II. :. Skin tear WITH partial tissue loss. Category III:. Skin tear with COMPLETE tissue loss, where the epidermal flab is absent. ID: 143617

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Bruising or Ecchymosis

Skin Tear Prevention


Category I:Skin tear WITHOUT tissue lossCategory II:Skin tear WITH partial tissue lossCategory III:Skin tear with COMPLETE tissue loss, where the epidermal flab is absent

Parameters of assessment


Prevention is #1 intervention!Provide a safe environmentPerform risk assessment of elderly patients on admissionImplement prevention protocol for patients identified as AT RISK FOR skin tears and bruising of skinPatients can wear long sleeves or pants to protect their extremities (if appropriate and applicable)Have adequate light to reduce the risk for bumping into furniture or equipmentProvide a safe area for wandering

Strategies and Interventions


On the correct way of handling patients to PREVENT skin tearsMaintain nutrition and hydration status (if applicable)Offer fluids between meals (unless contraindicated)Use lotion, especially on dry skin – arms, legs, BIDObtain dietary consult (if indicated) – consult with your primary nurse

Educate staff or family caregivers


Use a lift sheet (draw sheet) to move and turn patientsUse transfer techniques that prevent friction or shearPad bedrails, wheelchair arms, and leg supportsSupport dangling arms and legs with pillows or blankets

Protect skin from self-injury or injury during routine care


Use non-adherent dressings on frail skinApply petroleum-based ointment, steri-strips, or a moist non adherent wound dressing such as hydrogel dressing with gauze as a secondary dressing (if ordered, indicated and within your scope of practice) telfa type dressings can also be usedIf you must use tape, be sure it is made of paper and remove GENTLY. Also, you can apply the tape to hydrocolloid strips placed strategically around the wound rather than directly onto fragile surrounding skin around the skin tear


Use gauze wraps, stockinettes, flexible netting, or other skin protective measures to secure dressing rather than tapeUse no-rinse soapless bathing products (if indicated)Keep skin from becoming dry, apply moisturizer (if indicated)

Protecting skin continued


Gently clean the skin tear with normal salineLet the area air dry or pat dry carefullyApproximate the skin tear flap (if indicated)Use caution if using film dressing as skin damage can occur when removing dressingConsider marking an arrow on skin tear dressing to indicate the direction of the skin tear to minimize any further skin injury during removal

Treating skin tears


When you identify that your patient has bruising and/or skin tears on integument please follow the following protocols:Notify supervisor that a skin tear has occurred by you (via phone)Notify facility charge nurse (or primary nurse) the occurrenceFill out incident report form (for QA tracking and trending) and give to supervisor (Joanne)Document occurrence accurately and thoroughly


reporting policy


www.hhs.govUS Department of Health and Human


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