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...

...es the Patient Have Risk Factors for Pressure...


...ble 2. Surveyor Guidance: Risk Fac...


...e the Patient's Skin Thoroughly to Identify...


Assessment

...essment...

...TEP 3: Assess the Patient's Ove...

...3. Risk Factors to Consider in Ulcer Ass...


...tify Factors That Can Affect Ulcer Treatme...

...Table 4. Assessing Risk Factors for Press...


...Characterize the Pressure...

...e Ulcer Staging — MDS and National...


...6: Identify Priorities in Managing The Ulcer and...


Management/Treatment

Management/Treatm...

...7: Establish a Realistic, Individualized In...

...7. Physical Factors That May Influe...


...de General Support for the Patient...


...8. Nutritional Supplementation to Prom...


...Manage Pressure...


...teristics of Available Support Surfaces...


...: Manage Colonized or Infected Ulcers...


...TEP 11: Debride Necrotic Tissue from the Ulcer...


...hods of DebridementHaving trouble viewing tab...


...er and Protect the Ulcer and Surrou...


...Options for Pressure Ulcer Dressing...


...TEP 13: Recognize and Manage Ulcer Complication...


STEP 14: Consider Adjunctive Thera...


...15: Manage, Venous, Arterial, Neuropathic, and...

...cers  Compression is the mainst...

...s  For non-healing ulcers or in pati...

...and Diabetic Wounds  The most common c...

Skin Tears  The most important issue with skin...


...12. Recommendations on the Use of Inter...


...TEP 16: Monitor The Progress of Both Patient...


.... Recommended Components of Pressure Ulcer Documen...


...17: Decide Whether to Change Approaches t...


...the Facility's Management of Pressur...


...14. Sample Performance Measurement Indicato...


Glossary

...aryBiofilm: Aggregate of microorganisms in...