Pressure Ulcers And Other Wounds In The Post-Acute And Long-Term Care Setting

Publication Date: November 1, 2017
Last Updated: December 16, 2022

Assessment

Develop a structured program for timely skin assessment. ( Strong , High )
704

Assess nonhealing wounds for infection or biofilm using a tool such as NERDS (Nonhealing, inflammatory Exudate, Red granulation tissue, Debris, and Smell) or clinical observation. ( Insufficient , Low )
704

Classify/characterize pressure ulcers based on MDS criteria. ( Weak , Low )
704

Treatment/Prevention/Monitoring

Employ preventive measures such as promoting hydration and avoiding excessive skin moisture. ( Strong , Moderate )
704

Employ repositioning or offloading measures as needed (includes support surfaces).

PREVENTION
  • Repositioning
  • Support surfaces:
  • Advanced static mattress
  • Alternating air
  • Sophisticated wheelchair cushion
TREATMENT
  • Support surfaces:
  • Air-fluidized bed
  • Alternating-pressure bed
  • Low-air-loss mattress
( Strong , Moderate )
704

Cleanse wounds with nontoxic products. ( Insufficient , Low )
704

Patients with a pressure ulcer nearing the end of life require the balance of best practice in wound treatment and prevention while promoting patient dignity and quality of life. ( Strong , Low )
704

Write a facility policy for assessment and treatment of pressure ulcers and other wounds with the goal of using it to develop realistic, individualized, interdisciplinary care plans. ( Strong , Low )
704

Recommendation Grading

Overview

Title

Pressure Ulcers And Other Wounds In The Post-Acute And Long-Term Care Setting

Authoring Organization

Publication Month/Year

November 1, 2017

Last Updated Month/Year

April 13, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Long term care

Intended Users

Podiatrist, physician, nurse, nurse practitioner, physician assistant

Scope

Prevention, Management

Keywords

pressure ulcer, Wound Management