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

Last updated March 17, 2022

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

...Recognit...

...STE...

...urveyor Guidance: Risk Factors for D...

...STEP 2: Examine the...

Assessment

...Assessment...

...STEP...

...ctors to Consider in Ulcer Assessment/Risk...

 Table 4. Assessing Risk Factors for Pressure...

...STEP 5: Characteri...

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

...STEP 6: Ident...

Management/Treatment

...Management/Treat...

...STEP 7: Establish...

...cal Factors That May Influence Pressure Ulcer Tre...

ST...

Table 8. Nutritional Supplementation t...

...STEP 9:...

...eristics of Available Support Surfaces ...

...STEP 10: Man...

...STEP 11: Debride Ne...

...Methods of Debridement Type of...

...s for Pressure Ulcer Dressings ...

...STEP...

...STEP 14...

...STEP 15: Man...

...Ulcers  Compression is the mainstay of...

...Wounds  For non-healing ulcers or in pat...

...europathic and Diabetic Wounds  The...

Skin Tears  The most important issue with s...

...ble 12. Recommendations on the Use of Interventi...

...STEP 16:...

...e 13. Recommended Components of Pressure...

...STEP 17...

...STEP 18: Monitor t...

...ample Performance Measurement Indi...

Glossary

...yBiofilm: Aggregate of microorganisms...