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
PREVENTION
- Repositioning
- Support surfaces:
- Advanced static mattress
- Alternating air
- Sophisticated wheelchair cushion
- Support surfaces:
- Air-fluidized bed
- Alternating-pressure bed
- Low-air-loss mattress
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
Disclaimer
Overview
Title
Pressure Ulcers And Other Wounds In The Post-Acute And Long-Term Care Setting
Authoring Organization
American Medical Directors Association/Society for Post Acute and Long-term Care
Publication Month/Year
November 1, 2017
Last Updated Month/Year
April 13, 2023
Supplemental Implementation Tools
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