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...

...Does the Patient Have Risk Factors...

...Surveyor Guidance: Risk Factors for Developing...

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

Assessment

...sessment...

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

...ctors to Consider in Ulcer Assessment...

...Identify Factors That Can Affect Ulcer Tre...

...4. Assessing Risk Factors for Pressure UlcersHa...

...aracterize the Pressure Ulcer...

.... Pressure Ulcer Staging — MDS and National...

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

Management/Treatment

...anagement/Treat...

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

...hysical Factors That May Influence Pressure Ul...

...Provide General Support for the Patien...

...ble 8. Nutritional Supplementation to Promot...

...9: Manage Pressure...

...le 9. Characteristics of Available Suppo...

...ge Colonized or Infected Ulcers...

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

...Methods of DebridementHaving trouble viewi...

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

...Options for Pressure Ulcer Dressings H...

...cognize and Manage Ulcer Complications...

...r Adjunctive Therapies when Standa...

...Venous, Arterial, Neuropathic, and Othe...

...ous Stasis Ulcers  Compression is...

...ounds  For non-healing ulcers or...

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

...  The most important issue with skin tears i...

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

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

...Recommended Components of Pressure U...

STEP 17: Decide Whether to Change A...

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

...14. Sample Performance Measurement Indicators...

Glossary

...: Aggregate of microorganisms in which...