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

Recogniti...

...he Patient Have Risk Factors for Pressure Ul...

...r Guidance: Risk Factors for Developing...

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

Assessment

...ssessment...

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

...Risk Factors to Consider in Ulcer Assessment/RiskH...

...entify Factors That Can Affect Ulcer Tr...

...sing Risk Factors for Pressure UlcersHaving troub...

...P 5: Characterize the Pressure Ulcer...

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

...dentify Priorities in Managing The Ulcer and t...

Management/Treatment

...ment/Treatment

...blish a Realistic, Individualized Inter...

...e 7. Physical Factors That May Influence Pressur...

...Provide General Support for the Patient...

...8. Nutritional Supplementation to Promote Skin I...

...e Pressure...

...aracteristics of Available Support Su...

...10: Manage Colonized or Infected Ulc...

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

...10. Methods of DebridementHaving trouble vie...

...Cover and Protect the Ulcer and Surrounding Sk...

...11. Options for Pressure Ulcer Dressin...

...13: Recognize and Manage Ulcer Com...

...onsider Adjunctive Therapies when Standard...

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

...sis Ulcers  Compression is the m...

...  For non-healing ulcers or in patie...

...ic and Diabetic Wounds  The most common ca...

...n Tears  The most important issue with skin t...

...le 12. Recommendations on the Use of Interven...

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

...3. Recommended Components of Pressure Ul...

...EP 17: Decide Whether to Change Ap...

...8: Monitor the Facility's Management...

Table 14. Sample Performance Measurement Indic...

Glossary

...lossaryBiofilm: Aggregate of micro...