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

...ognition

...Patient Have Risk Factors for Pressure Ulcer...

...2. Surveyor Guidance: Risk Factors for De...

...Examine the Patient's Skin Thoro...

Assessment

...ssessme...

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

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

...tify Factors That Can Affect Ulcer Tre...

...essing Risk Factors for Pressure UlcersHaving tr...

...haracterize the Pressure U...

...le 5. Pressure Ulcer Staging — MDS an...

...TEP 6: Identify Priorities in Managing The Ul...

Management/Treatment

...ment/Treatment...

...tablish a Realistic, Individualized Interp...

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

...ovide General Support for the Patient...

...tional Supplementation to Promote Skin Integrity...

...anage Pressure...

...e 9. Characteristics of Available Support Surf...

STEP 10: Manage Colonized or Infected U...

...ebride Necrotic Tissue from the Ulcer...

...e 10. Methods of DebridementHaving...

...: Cover and Protect the Ulcer and...

...Options for Pressure Ulcer Dressings Havi...

...P 13: Recognize and Manage Ulcer Complicat...

...der Adjunctive Therapies when Standard Therapies...

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

Venous Stasis Ulcers  Compression is the ma...

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

...athic and Diabetic Wounds  The most c...

...The most important issue with skin tears is t...

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

...nitor The Progress of Both Patient and Ulcer...

...commended Components of Pressure Ulcer Doc...

...de Whether to Change Approaches to...

STEP 18: Monitor the Facility's...

...e 14. Sample Performance Measurement...

Glossary

...ssaryBiofilm: Aggregate of microorganisms i...