Pressure Ulcers and other Wounds in the Post-Acute and Long-Term Care Setting

Publication Date: November 1, 2017

Key Points

Key Points

Table 1. Summary of Recommendations and Their Grading


Recognition

Select and consistently use one predictive scale to identify patients at high risk for the development of pressure ulcers or other wounds. Although predictive scales vary in their predictive value, the consistent use of one scale is the most reliable way to detect change over time. ( Strong , Moderate )
704
Write a care plan to address identified risk factors based on minimum data set (MDS) variables. ( Weak , Moderate )
704

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

Recognition

...ecogniti...

...s the Patient Have Risk Factors for Pr...


...yor Guidance: Risk Factors for Developing Pressur...


...2: Examine the Patient's Skin...


Assessment

Assessm...

...3: Assess the Patient's Overall Physical...

...Risk Factors to Consider in Ulcer A...


...P 4: Identify Factors That Can Affect U...

...Assessing Risk Factors for Pressure UlcersHa...


...haracterize the Pressure U...

...able 5. Pressure Ulcer Staging — MDS and Nationa...


STEP 6: Identify Priorities in Managing The...


Management/Treatment

...gement/Treatmen...

...lish a Realistic, Individualized Int...

...cal Factors That May Influence Pressur...


...8: Provide General Support for the Patient...


...utritional Supplementation to Promote Skin Integr...


...Pressure...


...haracteristics of Available Support...


...Colonized or Infected Ulcers...


...: Debride Necrotic Tissue from the Ulcer...


...able 10. Methods of DebridementHaving trou...


...P 12: Cover and Protect the Ulcer and Surrou...


.... Options for Pressure Ulcer Dressings Ha...


...ize and Manage Ulcer Complications...


...Consider Adjunctive Therapies when Standard Th...


...Venous, Arterial, Neuropathic, and Other...

...ous Stasis Ulcers  Compression is the...

...ds  For non-healing ulcers or in patients wi...

...europathic and Diabetic Wounds  The mos...

...he most important issue with skin tear...


...ecommendations on the Use of Interventions t...


...P 16: Monitor The Progress of Both Patient and...


...ommended Components of Pressure Ulcer Documentatio...


...Whether to Change Approaches to Managing...


...Monitor the Facility's Management of P...


...mple Performance Measurement Indicators...


Glossary

...ilm: Aggregate of microorganisms in which cells...