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

...cognition...

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


.... Surveyor Guidance: Risk Factors f...


...: Examine the Patient's Skin Thoroughly to Id...


Assessment

Assessm...

...ssess the Patient's Overall Physical and P...

...Factors to Consider in Ulcer Assess...


...TEP 4: Identify Factors That Can Affect...

...Table 4. Assessing Risk Factors for Pressure Ulcer...


...Characterize the Pressure Ulcer...

.... Pressure Ulcer Staging — MDS and Nat...


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


Management/Treatment

...ement/Treatment...

...blish a Realistic, Individualized Interprofession...

...ysical Factors That May Influence P...


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


...tritional Supplementation to Promote S...


...9: Manage Pressure...


...haracteristics of Available Support Surfaces...


...age Colonized or Infected Ulcers...


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


...Methods of DebridementHaving trouble...


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


...tions for Pressure Ulcer DressingsÂ...


...ecognize and Manage Ulcer Complications...


...4: Consider Adjunctive Therapies when...


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

...nous Stasis Ulcers  Compression is...

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

...Diabetic Wounds  The most common...

Skin Tears  The most important issue...


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


...EP 16: Monitor The Progress of Both...


...ended Components of Pressure Ulcer Documentation...


...: Decide Whether to Change Approach...


...or the Facility's Management of Pressure U...


...14. Sample Performance Measurement Ind...


Glossary

...ryBiofilm: Aggregate of microorgani...