The Respiratory Care Practitioner will do a physical check of the skin contacted by the oxygen device at least once per shift and document skin assessment in the Respiratory Care Clinical Record/Compass forms
The Respiratory Care Practitioner will check the patients Braden Q score and if the score is less than 23 or the patient has skin breakdown, the patient will be considered at risk and a WOCN consult should be placed by the Respiratory Care Practitioner or Nurse
The WOCN referral number should be documented in Compass as a communication order or documented on the Critical Care Nurses Notes. Ensure reason for referral is documented
Preventative Skin Care options for patients with Nasal Cannula/Oxygen Mask Therapy
Use Tender Grips to cheeks to secure the nasal cannula
High flow nasal cannula (HFNC) patients:
RCP will fit the patient with prongs that occlude no more than 60% of the nare(s)
RCP will verify appropriate prong position q4 and PRN
All HFNCs will be secured to cheeks with Tender Grips (small), adhesive Velcro eggs, or F&P Wiggle Pads
The Respiratory Care Practitioner will notify the RN immediately if they identify redness from an oxygen therapy device
Consider use of Mepilex Lite over ears when long-term oxygen mask therapy will be required
Skin Care Intervention when Redness / Breakdown are Identified with patients on Nasal Cannula/Oxygen Mask Therapy
The Respiratory Care Practitioner will apply Mepilex Lite to skin if any redness is noticed over the ears and/or where the oxygen device rests on the skin
Place WOCN consult. Multiple referrals for the same skin breakdown issue are unnecessary
Steps to the BIPAP Skin Care Guidelines
If a Patient requires BIPAP, place wound care consult and notify bedside RN. Then apply Mepitel to nose and Mepilex Border to back of neck. You will do a Full Skin Assessment Q 4 hours where you offload the mask, inspect skin and replace skin barriers (Mepitel and Mepilex Border). Ensure a complete inspection of skin under the mask and straps neck
Alternate mask types (nasal, full mask, etc.) with Q4 assessment if patient can tolerate different masks
IF redness or pressure injury is noted during a Q4 assessment or if the patient cannot tolerate mask changes and has to use the mask best tolerated, begin Q2 full skin assessment with a change in skin barrier Q4
Contact Wound Care Nurse, RT Manager and notify MD for further instructions if redness or pressure injury noted
High Risk Patients on Bipap
Requiring Q2 hour full skin assessments
History of skin breakdown
History of poor healing
Prominate nasal bridge
Facial structure that inhibits a proper mask fit
Reminders for patients on BIPAP/NIV
Do not use sween cream
Do not apply any product, other than Mepitel or Mepilex Border, without physician or wound care orders
Collaborate as a team (Peer Checking) at least once per shift during a Q 4 or Q 2 hour assessment WITH the nurse, respiratory therapist and Provider
Preventative Skin Care for the Orally Intubated Patient
Apply Cavilon Skin Prep to cheeks and upper lip
Apply Mastisol adhesiveto cheeks and upper lip
Apply white adhesive tape to secure ETT
Ensure ETT tape does not pinch skin between tape and ETT
Use ventilator arm
Document procedure in Respiratory Care Record/Compass
Preventative Skin Care for the Nasally Intubated Patient
Apply Cavilon Skin Prep to cheeks and upper lip
Apply Mastisol adhesive to cheeks and upper lip
Apply white adhesive tape to secure ETT under nare
Ensure ETT does not pull upward onto nare
Use ventilator arm to prevent pulling of ETT upward on nare
Document procedure in Respiratory Care Record/Compass
When there is Redness or Skin Breakdown on All Ventilated Patients
Try to avoid the device/tape contacting the area(s) of breakdown
Apply Mepilex Lite to the area(s) of breakdown under the device/tape if avoidance is not possible
Place WOCN referral. Multiple referrals for the same skin breakdown issue are unnecessary
Document dressing application in Respiratory Care Record/Compass