Download Pressure Ulcer Toolkit for Nursing Homes

Gauging Pressure Ulcers:
A Nursing Home’s
Guide to Prevention
and Treatment
Gauging Pressure Ulcers: Introduction
Pressure ulcers are a significant problem across all ages and health care settings. Multiple factors put
residents at risk for developing a pressure ulcer, including immobility, chronic illness, incontinence, poor
nutrition, altered level of consciousness, altered sensory perception and a history of having pressure
ulcers.1
Pressure ulcers come at a high cost to everyone. They result in pain, suffering, diminished quality of life
and even death for some residents. For a nursing home, they represent extra staff hours and medical
supplies spent caring for a preventable condition, as well as more residents hospitalized. The cost of
treating a single full-thickness pressure ulcer can be as high as $70,000, with the total treatment cost for
pressure ulcers in the US surpassing $11 billion per year.2
Although pressure ulcers are preventable, more than one in every 10 of Missouri nursing home residents
developed a pressure ulcer in 2007. The Centers for Medicare & Medicaid Services has long focused on
helping nursing homes prevent pressure ulcers, but in 2008 they extended this effort across care settings.
Hospitals now have a payment incentive to partner with nursing homes on pressure ulcer prevention
– a good thing since 20 percent of nursing home pressure ulcers originate outside the nursing home,
generally in the acute hospital setting.
No matter where you are in your prevention efforts, now is the time to take a look at your care processes
with fresh eyes. First, review what the law says about pressure ulcers. See this toolkit’s summary of the
federal guidelines – Understanding CMS Interpretation of Tag F314. Then, use the included Pressure
Ulcer Facility Assessment Checklists to take a critical look at your current practices. Every one of these
systems is crucial to pressure ulcer prevention, so take your time completing this assessment. As you
assess, call on other staff to help you answer questions completely and honestly. Once you’ve completed
the assessment and identified key areas for improvement, review the clinical reference tools, reminder
tools and sample forms included in this toolkit. Feel free to adapt them to meet your individual needs.
1
2
Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006; 296: 974-984.
Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006;296:974-984.
Pressure Ulcers: Table of Contents
This table of contents provides an overview of the assessment and clinical reference tools for pressure
ulcers contained in this document. For further information, see the following pages for tool descriptions
organized by section. If you’re viewing this document on your computer, click on the tool name in the
table of contents below, and you will be taken directly to the resource. To download and print tools
individually, go to www.primaris.org.
I. Guidelines and Example Policies
a. Understanding CMS Interpretation of F314
b. MDS Skin Condition Coding Tip Sheet
II. Facility Assessment and Protocols
a. Facility Assessment Checklists
b. Sample Protocol
III. Resident Assessment and Monitoring Tools
a. Braden Scale
b. Skin Tear Risk Assessment
c. LTC Dehydration Risk Assessment
d. Comprehensive Admission Skin Assessment
e. Licensed Nurse Weekly Skin Assessment
f. CNA Shower Assessment
g. Daily Skin Monitoring Tool
h. Systems Investigative Audit Tool
IV. Prevention Tools
a. Pressure Ulcer Prediction, Prevention and Treatment Pathway
b. Tissue Tolerance and Individualized Turning Schedule
c. Managing Tissue Loads
d. Support Surface Characteristics and Considerations
V. Treatment Tools
a. Treatment Product Categories
b. Nutritional Wound Healing Guidelines
c. Selected Characteristics for Support Surfaces
VI. Communication Among Providers
a. SBAR Skin Care Instructions
VII. Education
a. Resident and Family Education (PUP) Brochure
b. Facility/staff education
i. Staging Guidelines from National Pressure Ulcer Advisory Panel
ii. Pressure Ulcer Classification Pocket Cards (see www.primaris.org)
iii. CNA Knowledge and Attitude Survey
Pressure Ulcers: Tool Descriptions
I. Guidelines and Example Policies
Understanding CMS Interpretation of F314: Summarizes the changes that CMS put into place with the revision of F-Tag
314. Any time you make changes, quickly review this summary to ensure that you are meeting federal guidelines.
MDS Skin Condition Coding Tip Sheet: Use this tip sheet to see, at a glance, how your coding questions might be
addressed by the RAI manual.
II. Facility Assessment and Protocols
Facility Assessment Checklists: Complete this checklist as you review your approach to pressure ulcer prevention and
treatment. It will help determine your plan’s comprehensiveness, its alignment with F-Tag 314 and good clinical practice.
Sample Protocol: Use this protocol as a guideline for establishing a comprehensive Pressure Ulcer Prevention and
Management Policy. Download the file as a separate Word document and modify it to suit your practices and materials.
III. Resident Assessment and Monitoring Tools
Braden Scale: The Braden Scale is a research-based risk assessment used widely in the nursing community. The format
allows for four separate assessments to aid in monitoring change over time.
Skin Tear Risk Assessment: Evaluating for skin tear risk and interventions is different than evaluating for pressure ulcer
risk. The skin is our first line of defense, and we must protect the skin not only from pressure ulcers but from skin tears
as well. This assessment helps determine if a resident is at risk for skin tears and offers potential interventions and a chart
review audit, encouraging staff follow-through.
LTC Dehydration Risk Assessment: Inadequate fluid intake can place residents at increased risk for pressure ulcers. This
tool will help determine resident dehydration risk, enabling staff to take a proactive approach.
Comprehensive Admission Skin Assessment: Conducting a baseline comprehensive assessment of the skin is vital. Staff
may use this form to guide them through the assessment.
Licensed Nurse Weekly Skin Assessment: All residents should have their skin assessed weekly by a licensed nurse. This
form encourages continuity in this documentation.
CNA Shower Assessment: This form recognizes the important role CNAs play in pressure ulcer prevention and empowers
them to do regular skin checks. It provides a formal method of communication to the licensed nurses of their review of
residents’ skin, which then would be followed up by the licensed staff.
Daily Skin Monitoring Tool: This tool provides a formal approach for CNAs to report areas of concern with the resident’s
skin daily. The licensed staff would then follow-up on noted areas of concern to provide a complete assessment.
Systems Investigative Audit Tool: Use this tool as a guide during a chart review to ensure all appropriate steps are being
taken for pressure ulcer prevention and management.
continued on next page >
Pressure Ulcers: Tool Descriptions
IV. Prevention Tools
Pressure Ulcer Prediction, Prevention and Treatment Pathway: This pathway assists staff in determining the appropriate
care for the individual resident. It aids in staff critical thinking skills to ensure all areas of concern are met.
Tissue Tolerance and Individualized Turning Schedule: This form can be used to document the assessment that led to
the individualized turning schedule.
Managing Tissue Loads: Use this tool to systematically choose the right mattress or wheel chair cushion, based upon a
resident’s level of need.
Support Surfaces: Characteristics and Considerations: Use this in-depth reference to learn more about the different
support surfaces available for pressure ulcer prevention or treatment.
V. Treatment Tools
Treatment Product Categories: Use this list outlining the major types of products to ensure your nursing center carries
an appropriate range of materials for pressure ulcer treatment. Nursing staff should choose the most effective dressing type
based on wound stage, characteristics and potential concerns.
Nutritional Wound Healing Guidelines: This sample procedure helps enhance pressure ulcer healing by providing
recommendations for nutritional intervention whenever possible. These are guidelines only. Individual patient and resident
needs must be taken into consideration before implementation.
Selected Characteristics for Support Surfaces: This quick visual reference compares the characteristics of the different
types of support surfaces.
VI. Communication Among Providers
SBAR Skin Care Instructions Form: Provides a standardized format for communication using the SBAR (Situation,
Background, Assessment, Recommendations) model. This form would be used in communication from wound care nurse
to unit nurse for the prevention and/or management of pressure ulcers.
VII. Education
Resident and Family Education Brochure (PUP): Use this brochure to proactively inform residents and families about
individual risk factors and prevention techniques associated with skin breakdown so they can be be involved in prevention.
Staging Guidelines (National Pressure Ulcer Advisory Panel): These are the most up-to-date guidelines for assessing the
state and the subsequent documentation of pressure ulcers.
Pressure Ulcer Classification Pocket Cards: Two double-sided reference cards were designed to assist clinical staff in
the assessment, measurement and documentation of wounds. Go to www.primaris.org to download a pdf of the cards.
Primaris partner homes may order laminated copies.
CNA Knowledge and Attitude Survey: CNAs’ participation is vital for the prevention of pressure ulcers. This survey will
assess what your CNAs know about pressure ulcers and discover areas in which they could benefit from further education.
Understanding CMS Interpretation of F314
This document summarizes key points of CMS guideline Tag F314, which state surveyors use as guidance to
help them assess nursing homes’ pressure ulcer prevention and treatment. Use this as guidance for assessing the
processes in place at your home with regard to pressure ulcer prevention, assessment, intervention, monitoring
and care planning.
Regulations: Pressure Ulcers
F314 42 CFR 483.25 (c) Pressure sores
Based on the comprehensive assessment of a resident, the facility must ensure that –
• A resident who enters the facility without pressure sores does not develop pressure sores unless the
individual’s clinical condition demonstrates that they were unavoidable; and
• A resident having pressure sores receives necessary treatment and services to promote healing, prevent
infection and prevent new sores from developing”
F314 Intent
• Promote the prevention of pressure ulcer development
• Promote healing of pressure ulcers that are present
• Prevent development of new pressure ulcers
Survey: Pressure Sore Investigative Protocol
Objective:
• To determine if the identified pressure sore(s) is avoidable or unavoidable
• To determine the adequacy of the facility’s pressure sore treatment interventions
Risk Management
• Identify and manage resident and facility risks
• Prevention of pressure ulcers benefits everyone
• Educate all staff on an ongoing basis
• Provide care based on accepted standards of practice (WOCN, AHQR, NPUAP)
• Document care based on accepted standards
• Make Care plans realistic especially when discussed with family in care plan conferences
• Watch for indicators of major system failures and initiate quality improvement activities
• Document facts, not assumptions
• Rising litigation
– What happens when the treatment sheet is not signed off?
– What happens when one lapse in weekly assessment occurs in a period where the wound declines?
– *Careful with dressings that stay on several days: What happens with weekly assess?
– Carefully consider policies on wound photography: may be “double-edge” sword
Understanding CMS Interpretation of F314: page 2
Three Key Factors for Risk Management
• Medical record must show standard of care for pressure ulcers was adhered to
• Medical record must have documentation of resident complications, risk factors, and/or underlying disease
that made the pressure ulcer unavoidable (if it is indeed)
• You must provide a comprehensive and aggressive program to prevent and treat the pressure ulcer (within
the parameters of resident advance directives)
Prevention
• What systems are in place in your facility?
– How is risk communicated to staff?
– Are there protocols for repositioning and pressure relief products that are understood by staff?
– How are you sure this is done for new admissions or those with change in status?
– Residents cannot afford to wait!
• How are moisturizers/barriers stocked?
• During “off-hours,” do staff know how to access pressure-reducing devices?
• Are tracking and assessment forms stocked?
• How are disposable briefs and underpads stocked and used?
Assessment
Avoidable vs. Unavoidable Pressure Ulcers
• Avoidable – Pressure ulcer developed and facility failed to do one or more:
▷ Defined/implemented interventions CONSISTENT with resident needs, goals
▷ Recognized standards of practice (AHCPR, AMDA, WOCN, current literature)
▷ Monitor and evaluate impact of interventions
▷ Revise interventions appropriately
• Unavoidable – Resident developed pressure ulcer although facility:
▷ Evaluated clinical condition and risk factors
▷ Defined and implemented interventions consistent with resident’s needs, goals, standards of practice
▷ Monitored and evaluated impact of interventions
▷ Revised approaches appropriately
Frequency of Risk Assessment (Braden or Norton most common)
• Minimally
▷ upon admission
▷ quarterly
▷ upon Significant Change in Condition
• Best Practice
▷ day 7, 14, 21, 28 (post-admission) then as above
▷ during acute illness
Understanding CMS Interpretation of F314: page 3
Wound Assessment
•
•
•
•
Assessment includes a full description of the wound and peri-wound
Measurements alone do not constitute an assessment
Reassess weekly at a minimum
Reassess daily if pressure ulcer is deteriorating
Staging Assessment
•
•
•
•
Does your facility policy address your process for staging?
Who does initial staging? How is it confirmed?
What are you staging? All open areas or only pressure ulcers?
Is there a facility tool for documenting staging?
Risk Assessment – Facility Wide
•
•
•
•
Establish written guidelines, protocols, algorithms/decision trees based on risk
Low risk does not equal no risk
Let low scores trigger your mind clinically: don’t just treat the conglomerate of score
Use appropriate interventions based on the risk assessment
Interventions
Address Risk Factors
•
•
•
•
•
•
•
Skincare: routine inspections, cleansing, moisturizing, avoid massage
Repositioning: 1 hour in chair by staff, 15 minutes in chair by resident; 2 hours in bed
Pressurerelief for heels
Pressurereduction devices
Addressnutrition
Addressincontinence
Toileting schedule? Rehab? Positioning evaluations? Incontinence products?
Combination of Prevention Interventions
•
•
•
•
Adequate nutrition and hydration
Repositioning schedule and positioning
Appropriate support surfaces
Care of skin
Monitoring Wound Status
Is It Better or Worse?
• Objectively review wound progress: measurements, type of tissue, PUSH tool
• Subjective assessments are problematic:
– “I don’t think this treatment is working. I’m calling the MD to change the treatment…”
– “The pressure ulcer is deeper than last week - of course it is worse” - not necessarily true
Understanding CMS Interpretation of F314: page 4
Monitoring Treatment Plan
• Is there a process for monitoring treatment?
• Is there a tracking tool to document response to treatment?
• Does the tracking form monitor the appropriate wound variables?
• Are there protocols for changing the treatment if it is ineffective?
• Healing - a systemic process affected by systemic conditions - treatment is more than a dressing
• When do you change the treatment?
• What determines frequency of dsg change
• How do you handle “non-traditional” recommendations or a product being used in a manner different than
its intended use?
Care Planning
• Do care plans identify risk factors?
• Are you treating the risk factors?
• Is the resident and family aware of and in agreement with goals?
• Goal must be a clear statement of intended progress and how it will be measured
• Be REALISTIC!!!!
• Determine what the goal is:
– Maintenance
– Improvement/Healing
– Comfort
– Many goals beyond healing…
▷ Resolution of periwound erythema in 2 weeks
▷ 25% reduction in amount of necrotic tissue by 1 week
▷ Decrease in intensity of pain during dressing changes from 6 to 3 (as reported by resident) by 1 week
▷ 1 cm reduction in wound dimensions by 2 weeks
Document available at www.primaris.org
MO-08-11-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare
& Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from CMS
Provider Certification, Transmittal 4, November 12, 2004; HCPro Pressure Ulcer Materials, 2004; & Pressure Ulcers F-314 by Courtney Lyder, September 2004
MDS Skin Condition Coding Tip Sheet
Definition
According the RAI Manual “A skin ulcer can be defined as a local loss of epidermis and variable levels of dermis and
subcutaneous tissue, or in the case of Stage 1 pressure ulcers, persistent area of skin redness (without a break in the skin) that
does not disappear when pressure is relieved.” (RAI Manual, pgs. 3-159)
CodingM1 - recording of all skin ulcers if caused by pressure or circulatory problems.
1. M1 - recording of all skin ulcers if caused by pressure or
circulatory problems.
4. M4 - records skin problems or lesions not caused by
pressure or circulatory problems.
2. M2 - differentiates between pressure or venous stasis
ulcers only; record highest level of each.
5. M5 - records any specific or generic skin treatments.
3. M3 - history of resolved/cured ulcers. Definition same as for M1.
6. M6 - records specific foot problems and care.
Process
1. Review the record and check with appropriate nursing
staff for the presence of any skin problems.
2. Examine the resident for condition (stage, number) of
any skin problems. Coding will be based on what is seen
(i.e. visible tissue) during the look back period. NPUAP
standards cannot be used for coding on the MDS. MDS
defined staging is used for M1 and M2 only.
3. Determine the cause of the skin ulcer. If it is caused from
pressure or circulation (venous or arterial) then it is coded
in M1. All remaining skin ulcers then are documented in
M4. (See pg 3-159) Record the number of skin ulcers caused
by either pressure or circulatory problems according to
stage for M1. M2 is for coding the highest stage of pressure
or venous stasis ulcers only.
4. Include in M4 all skin problems not caused by pressure,
venous stasis, circulatory problems or not coded anywhere
else in Section M.
5. Code all skin treatments in M5.
6. Code all foot problems and care in M6.
Clarification
1. Necrotic eschar prohibits accurate staging. Code the skin
ulcer with eschar as Stage 4 until debrided.
2. Good clinical practice dictates that the ulcer be re­
examined and re-staged after debridement.
3. If a skin ulcer is repaired with a flap graft, it is coded as a
surgical wound and not as a skin ulcer.
4. Skin ulcers should be coded in either M1, with further
clarification in M2, or in M4. Pressure or stasis ulcers
coded in M2 should not be coded in M4.
5. If skin ulcers are captured in M1 or M4, good clinical
practice would also have something documented in M5
under treatment.
6. For MDs coding, ankle problems are not considered foot
problems.
Documentation
1. For clinical practice facilities need to follow the NPUAP
standards in regards to pressure ulcer documentation (i.e.
Healing stage 4 that has the appearance of tissue size and
depth of a stage 2- the clinical record will state a healing
stage 4, but the MDS would have Stage 2 in M1.)
2. Document weekly assessments of the wound healing
progress or lack of. Documentation should include a
thorough description of size, drainage, etc.
3. Care planning should identify risk factors and interventions
based on the identified level of risk, as well as interventions to
facilitate healing of existing skin problems.
Example
1. Mrs. B has impaired arterial circulation to her right foot. She has a Stage 3 in appearance on the top of her foot. She also has a
superficial skin tear on her right forearm. M1 would be coded as a Stage 3 ulcer, M2 would be coded with 0 (zeros) and M4a
would be checked for the skin tear. M5d, e and g may be checked, depending on specified interventions. M6c would be checked.
Document available at www.primaris.org
MO-08-47-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Pressure Ulcers: Facility Assessment Checklists
A facility system assessment is a starting point for a quality improvement project. The checklists included in
this booklet will be most useful if you take a critical look at your current practices.
Directions for Pressure Ulcers: Facility Assessment Overview Questionnaire
• Tobecompletedbyadirectcareorinterdisciplinaryteam.
• Consultwithappropriatestaffinansweringcertainquestionsandcompletingchecklists.
• Ifyouanswer“No”toanyofthequestionsbelow,pleaseproceedimmediatelytothechecklist
referencedbythepageafterthequestion.
• Ifyouanswer“Yes”toaquestion,theprocessisalwayscompleteanddonesoconsistently.Please
continuetothenextquestion.
• Ifyouanswer“InProgress”toanyofthebelowquestions,theneedisbeingaddressedbutneedsimprovement.
Pressure Ulcers: Facility Assessment
Yes
No
In Progress
Does your facility have a process to screen residents for pressure ulcer risk? (page 2)
o
o
o
Does your facility have a process to develop and implement care plans for residents
who have been found to be at risk or have a pressure ulcer?
(pages 3-4)
o
o
o
Does your facility complete a comprehensive assessment for residents who are
found to have pressure ulcers upon screening or, if there is no screening process in
place, another time? (page 5)
o
o
o
For residents who have pressure ulcers, does your facility have a process for
monitoring treatment and prevention? (page 6)
o
o
o
Does your facility have a policy for pressure ulcer prevention and management?
(page 7)
o
o
o
Does your facility have initial and ongoing education on pressure ulcer prevention
and management for all relevant staff? (page 8)
o
o
o
When completing each checklist on the following pages:
• Ifyouanswer“Yes”toallofthequestions,theprocessisalwayscompleteanddonesoconsistently.
Continuetothenextchecklist.
• Ifyouarenotsure,oranswer“No”tooneofthequestions,chooseoneormoreelementsonwhichtofocus
yourqualityimprovement.
• Ifyouanswer“NeedsImprovement”tooneormoreofthequestions,theprocessisnotalwayscomplete
and/ornotalwaysdoneconsistently.
Pressure Ulcers: Facility Assessment Checklists: page 2
Pressure Ulcers: Screening for Pressure Ulcer Risk
Ascreeningassessmentisabriefassessmentorquestionthatdeterminesiftheresidentisatriskforpressure
ulcers.Itdoesnotincludeathoroughassessmentofthepressureulcerorwhatneedstobedoneiftheresidentis
foundtohaveapressureulceruponscreening.
Does your facility’s screening process include the following components?
Do you screen all residents for pressure ulcer risk at the following times?
Upon admission
Upon readmission
When change in condition
With each MDS assessment
If resident is not currently deemed at risk, is there a plan to rescreen at regular intervals?
Do you use either the Norton or Braden pressure ulcer risk assessment tool? (If yes, STOP.
If No, please continue to next question.) Note: Federal regulations (F-314) recommend the
use of standardized risk assessment tools.
Yes
No
Needs
Improvement
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
If you are not using the Norton or Braden risk assessment, does your screening address the following areas?
Impaired mobility:
Bed
o
o
o
Chair
o
o
o
Urine
o
o
o
Stool
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Incontinence:
Nutritional deficits:
Malnutrition
Feeding difficulties
Diagnosis of:
Diabetes mellitus
Peripheral vascular disease
Contractures
Hx of pressure ulcers
Completedby:_______________________________________ Date:______________________________
Pressure Ulcers: Facility Assessment Checklists: page 3
Pressure Ulcers: Developing Care Plans
Does the resident care plan address the following interventions and risk factors (as they apply)?
Impaired mobility
Assist with turning, rising, position
Encourage ambulation
Limit static sitting to 1 hour at any one time
Pressure relief
Support surfaces – bed
Support surfaces – chair
Pressure relieving devices
Repositioning
Check for “bottoming out” in bed and chair (To determine if a patient has bottomed out,
the caregiver should place his or her outstretched hand, palm-up, under the mattress
overlay below the existing pressure ulcer or that part of the body at risk for pressure
formation. If the caregiver can feel that the support material is less than an inch thick at
this site, the patient has bottomed out.)
Nutritional improvement
Supplements
Feeding assistance
Adequate fluid intake
Dietician consult as needed
Urinary incontinence
Cause identified and treated as appropriate
Toileting plan
Wet checks
Treat causes
Assist with hygiene
Fecal incontinence
Cause identified and treated as appropriate
Toileting plan
Soiled checks
Skin condition check
Check intactness
Color
Sensation
Temperature
Yes
No
Needs
Improvement
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
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continued on next page >
Pressure Ulcers: Facility Assessment Checklists: page 4
Pressure Ulcers: Developing Care Plans
Treatment
Physician prescribed regimen
Appropriateness to wound staging
Treatment reassessment time frame
Pain
Screen for pain related to ulcer
Choose appropriate pain med
Provide regular pain med administration
Reassess effectiveness of med
Assess/treat side effects
Change, increase or decease pain med as needed
Infection
Dressing containment
Keep dressing dry/intact
Assess for s/sx infection
Yes
No
Needs
Improvement
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
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o
Completedby:_______________________________________ Date:______________________________
Pressure Ulcers: Facility Assessment Checklists: page 5
Pressure Ulcers: Assessment and Reassessment
Does your comprehensive pressure ulcer assessment include the following components?
Do you have a tool available to document pressure ulcer assessment?
Yes
No
Needs
Improvement
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
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o
o
o
o
o
o
Does your current assessment of pressure ulcers include:
Location
Stage
Size
Undermining/tunneling
Wound bed (tissue)
Drainage/exudate
Peri wound tissue (color, temp, bogginess, and fluctuation)
Need for debridement
Is the resident’s pressure ulcer reassessed:
Weekly
Daily if worsening or high risk
Does reassessment include:
Size
Tunneling
Sinus tracts
Presence of necrotic tissue
Exudate
Granulation
Epithelialization
Color photos, diagram, or drawing
Are the following related factors considered in your assessment/reassessment:
Mechanical forces (shearing, friction, pressure)
Pronounced bony prominences
Poor nutrition
Altered cutaneous sensation
Completedby:_______________________________________ Date:______________________________
Pressure Ulcers: Facility Assessment Checklists: page 6
Pressure Ulcers: Monitoring Treatment and Prevention
Does your facility’s process for monitoring treatment and prevention include the following?
Yes
No
Needs
Improvement
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Does your facility have protocols to follow if current pressure ulcer treatment is
ineffective?
o
o
o
Does your facility have protocols to follow if ulcers are found to be non-healing?
o
o
o
Does your facility monitor pressure ulcers for the presence of infection (e.g., foul smell,
greenish drainage, cellulitis, osteomyelitis)?
Is there a list of possible interventions for the resident at each level of risk (low, moderate,
or high), that nursing staff may implement to prevent pressure ulcer development?
Does your facility have a protocol for management of tissue loads (e.g., positioning,
pressure relieving mattresses, dynamic mattress overlay)?
Are there adequate supplies to provide preventive interventions to all residents who
require them (e.g., adequate pressure reducing or relieving mattresses/chair cushions)?
o
o
o
o
o
o
o
o
o
o
o
o
Are pressure reducing or pressure relieving mattresses/chair cushions in good repair?
o
o
o
Are pressure reducing/relieving supplies available to staff on all shifts and whenever
needed?
Does your facility have protocols regarding pressure ulcer prevention that includes the
following:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Does your facility use a pressure ulcer tracking tool to document treatment and healing?
(If “No,” skip to question 3.)
Does the tracking form include the following:
Date
Stage
Current treatment
Color photo, diagram, or drawing
Size
Depth
Appearance (e.g., redness, presence of discharge, eschar formation)
Monitoring residents for incontinence
Need for assistance with mobility and bed mobility
Weight loss
Nutritional deficiency
Dehydration
Completedby:_______________________________________ Date:______________________________
Pressure Ulcers: Facility Assessment Checklists: page 7
Pressure Ulcers: Elimination
Does the pressure ulcer elimination process include the following components?
Yes
No
Needs
Improvement
Does your facility’s policy include a statement regarding your facility’s commitment to
pressure ulcer prevention and management?
o
o
o
Does your facility’s policy include screening, assessment, and monitoring of residents for
pressure ulcers?
o
o
o
Does your facility’s policy address measures that should be taken to prevent pressure
ulcers in residents?
o
o
o
If the resident is not currently deemed at risk, does your facility’s policy state that residents
should be screened for pressure ulcer risk at regular intervals?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Does your facility’s policy address steps to be taken if pressure ulcer is not healing?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Does your facility’s policy address a protocol for communication of reporting pressure
ulcer staging/healing to the designated MDS personnel to ensure correct coding?
o
o
o
Does your facility’s policy state that residents who are at risk for pressure ulcers be screened at the
following times:
Upon admission
Upon readmission
When a change in condition occurs
With each MDS assessment
Does your facility’s policy state that residents at high risk for pressure ulcers should be
screened daily?
Does your facility’s policy include who, how, and when pressure ulcer program effectiveness should be
monitored and evaluated?
Prompt assessment and treatment
Specification of appropriate pressure ulcer risk and monitoring tools
Steps to be taken to monitor treatment effectiveness
Pressure ulcer treatment techniques that are consistent with clinically-based guidelines
Optimize the resident’s ability to perform ADLs and participate in activities
Completedby:_______________________________________ Date:______________________________
Pressure Ulcers: Facility Assessment Checklists: page 8
Pressure Ulcers: Staff Training and Education
Does your facility’s training and education program include the following components?
Yes
No
Needs
Improvement
Are new staff assessed for their need for education on pressure ulcer prevention and management?
o
o
o
Are current staff provided with ongoing education on the principles of pressure ulcer
prevention and management?
o
o
o
Does education staff provide discipline-specific education for pressure ulcer prevention
and management?
o
o
o
Is there a designated clinical “expert” available at the facility to answer questions from all
staff about pressure ulcer prevention and management?
o
o
o
Is the education provided at the appropriate level for the learner (e.g., CNA vs. RN)?
o
o
o
Does the education include staff training on documentation methods related to pressure
ulcers (e.g., location, stage, size, depth, appearance, exudate, current treatment, effect on
ADL’s, pressure relieving devices used, nutritional support)?
o
o
o
Completedby:_______________________________________ Date:______________________________
Document available at www.primaris.org
MO-08-16-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Sample Protocol
Implement a protocol and accompanying strategies such as those below to help guide the care of
residents at risk for developing pressure ulcers. Systematic skin inspection
Turn/reposition every 2 hours (if mobility
impaired) or more often if needed
Turn/reposition every 2 hours and
prevent direct contact between bony
prominences
Protect heels
If bedfast, provide pressure­reducing
support surface
If in wheelchair, provide pressure­reducing
seat cushion
If appropriate, initiate remobilization
program (therapy if appropriate, ambulation, stand­pivot transfers, restorative nursing
etc)
Manage moisture (from incontinence)
Manage nutrition
Reduce friction/shear
Provide wedges/repositioning aids for 30
degree lateral positioning
Supplement turning schedule with small
position shifts (hourly)
Obtain rehab assessment to:
­ Determine need for pressure relief
cushion
­ Assess correct seat height and w/c
positioning
Consider a pressure relieving support surface or powered mattress overlay
Written plan of care
Staff education
At Risk
Moderate
Risk
High Risk
Very High
Risk
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Sample Protocol: page 2
Sample risk reduction strategies:
Skin inspection: All residents should be inspected at least daily. This can be done with dressing, undressing, toileting, bathing, peri­care, etc. Pay particular attention to bony prominences. Minimize exposure to low humidity. Moisturize dry skin.
Turning and repositioning: Keep bony prominences from direct contact using systematic turning and
repositioning and positioning devices such as pillows or foam wedges. Avoid positioning directly
on the trochanter. Determine tissue tolerance.
Wheelchair Positioning: OT evaluate for proper fit to wheelchair and appropriate pressure relieving
device. Reposition and off load eight hourly – stand if possible. Try to use at least three different
chair types daily to alter pressure points. If residents are able, teach or cue them to shift their own
weight every hour. Use a pressure­reducing device such as those made of foam, gel, air or a
combination of the two. Do not use donut­type devices. Heel Protection – Friction: To prevent friction, use “gripper” socks, sheepskin at foot of bed, transparent dressings or skin sealants, protective dressings (such as hydrocolloids), moisturizers
Heel Protection – Pressure: Keep ALL weight off residents’ heels. Elevate lower extremities with
pillows length­wise under lower legs, multi­podus boots, heel­lift boots, loosen bed linens at foot
of bed, foot cradle
Manage Incontinence: Initiate bowel/bladder program or scheduled toileting, incontinent care every
two hours, incontinence barriers, briefs, absorbent underpads (made with materials that absorb
moisture & present a quick drying surface to the skin), fecal bag (if frequent stools). Avoid hot
water, and use a mild cleansing agent that minimizes irritation and dryness. Manage Nutrition: Monitor for weight loss. Assess for chewing or swallowing problems. Provide a
combination of: dietician consults, supplements, vitamin supplements, hydration, feeding
assistance, adaptive equipment. Reduce friction/shear: Draw sheet or lift pad for bed movement, trapeze, moisturize skin, limit head
of bed elevation to 30 degrees (and only as required), long sleeve garments/elbow protectors, careful cleansing during incontinence/hygiene care, gait belt transfers (as appropriate), mechanical
lift. Pressure relieving mattress/overlay: Pressure reducing mattress types include, foam, static air, alternating air, gel or water mattresses.
Written plan of care: Each resident’s care plan should be unique, including specific turning and
repositioning plans. Indentify and address each factor noted in the Risk Assessment. Staff Education: Target prevention at all levels of health care, from providers to residents and
families. Identify the role each plays in pressure ulcer prevention. Implement a comprehensive
pressure ulcer prevention program.
References:
Agency for Health Care Policy and Research (1994). Treatment of Pressure Ulcers. AHCPR Pub. No 95­0652.
University of Iowa Nursing Interventions Research Center. Prevention of Pressure Ulcers
American Medical Directors Association. Pressure Ulcers in the Long­Term Care Setting Clinical Practice Guideline. Columbia, MD: AMDA
2008
Source: QIPMO: University of MO­Columbia, Sinclair School of Nursing, April 2008
MO­08­14­PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS
Braden Scale for Predicting Pressure Sore Risk
Resident Name (Last, First, Middle) ___________________________________________________________
Room #:_________ Attending Physician:_________________________Date of Assessment: _____________
Assessment Date:
Risk Factor
Score/Description
Sensory Perception
Ability to respond meaningfully to pressurerelated discomfort
1 = Completely Limited
2 = Very Limited
3 = Slightly Limited
4 = No impairment
Moisture
Degree to which skin is exposed to moisture
1 = Constantly Moist
2 = Often Moist
3 = Occasionally Moist
4 = Rarely Moist
Activity
Degree of physical activity
1 = Bedfast
2 = Chairfast
3 = Walks Occasionally
4 = Walks Freqeuently
Mobility
Ability to change and control body position
1 = Completely Immobile
2 = Very Limited
3 = Slightly Limited
4 = No Limitations
Nutrition
Usual food intake pattern
1NPO: Nothing by mouth
2IV: Intravenously
3TPN: Total parenteral nutrition
1 = Very Poor
2 = Probably Inadequate
3 = Adequate
4 = Excellent
Friction and Shear
1 = Problem
2 = Potential Problem
3 = No Apparent Problem
1
2
3
Total Score
High Risk: Total score ≤ 12. Moderate Risk: Total score 13-14. Low Risk: Total score 15-16 if under 75 years old or 15-18 if over 75 years old
For Detailed Descriptions, see page 2
Assess
Date
Evaluator signature/title
Assess
1
3
2
4
Date
Evaluator signature/title
NOTE: This form is copyrighted. Permission to reproduce this form may be obtained at no charge by accessing www.bradenscale.com/copyright.asp
page 1 of 2
4
Braden Scale for Predicting Pressure Sore Risk: page 2
Sensory Perception
Nutrition
1 = Completely Limited. Unresponsive (does not moan, flinch,
or grasp) to painful stimuli, due to diminished level of
consciousness or sedation OR limited ability to feel pain
over most of body.
2 = Very Limited. Responds only to painful stimuli. Cannot
communicate discomfort except by moaning or
restlessness OR has a sensory impairment which limits the
ability to feel pain or discomfort over ½ of body.
3 = Slightly Limited. Responds to verbal commands, but
cannot always communicate discomfort or the need to
be turned OR has some sensory impairment which limits
ability to feel pain or discomfort in 1 or 2 extremities.
4 = No impairment. Responds to verbal commands. Has no
sensory deficit which would limit ability to feel or voice
pain or discomfort.
1 = Very Poor. Never eats a complete meal. Rarely eats more
than ½ of any food offered. Eats 2 servings or less of
protein (meat or dairy products) per day. Takes fluids
poorly. Does not take a liquid dietary supplement OR is
NPO1 and/or maintained on clear liquids or IV2 for more
than 5 days.
2 = Probably Inadequate. Rarely eats a complete meal and
generally eats only about ½ of any food offered. Protein
intake includes only 3 servings of meat or dairy products
per day. Occasionally will take a dietary supplement OR
receives less than optimum amount of liquid diet or tube
feeding.
3 = Adequate. Eats over half of most meals. Eats a total of
4 servings of protein (meat, dairy products) per day.
Occasionally will refuse a meal, but will usually take a
supplement if offered OR is on a tube feeding or TPN3
regimen, which probably meets most of nutritional needs.
4 = Excellent. Eats most of every meal. Never refuses a meal.
Usually eats a total of 4 or more servings of meat and dairy
products. Occasionally eats between meals. Does not
require supplementation.
Moisture
1 = Constantly Moist. Skin is kept moist almost constantly by
perspiration, urine, etc. Dampness is detected every time
patient is moved or turned.
2 = Often Moist. Skin is often, but not always moist. Linen
must be changed at least once a shift.
3 = Occasionally Moist. Skin is occasionally moist, requiring an
extra linen change approximately once a day.
4 = Rarely Moist. Skin is usually dry; linen only requires
changing at routine intervals.
Activity
1 = Bedfast. Confined to bed.
2 = Chairfast. Ability to walk severely limited or nonexistent.
Cannot bear own weight and/or must be assisted into chair
or wheelchair.
3 = Walks Occasionally. Walks occasionally during day, but for
very short distances, with or without assistance. Spends
majority of each shift in bed or chair.
4 = Walks Frequently. Walks outside room at least twice a
day and inside room at least once every 2 hours during
waking hours.
Friction and Shear
1 = Problem. Requires moderate to maximum assistance in
moving. Complete lifting without sliding against sheets is
impossible. Frequently slides down in bed or chair, requiring
frequent repositioning with maximum assistance. Spasticity,
contractures or agitation leads to almost constant friction.
2 = Potential Problem. Moves feebly or requires minimum
assistance. During a move, skin probably slides to some
extent against sheets, chair, restraints, or other devices.
Maintains relatively good position in chair or bed most of
the time but occasionally slides down.
3 = No Apparent Problem. Moves in bed and in chair
independently and has sufficient muscle strength to lift up
completely during move. Maintains good position in bed or
chair at all times.
Mobility
1 = Completely Immobile. Does not make even slight changes
in body or extremity position without assistance.
2 = Very Limited. Makes occasional slight changes in body
or extremity position but unable to make frequent or
significant changes independently.
3 = Slightly Limited. Makes frequent though slight changes in
body or extremity position independently.
4 = No Limitations. Makes major and frequent changes in
position without assistance.
Document available at www.primaris.org
MO-08-12-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare &
Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
© Copyright Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission.
Skin Tear Risk Assessment
Resident: ___________________________________________________________ Date:_________________
This form should be completed in conjunction with the Skin Risk Assessment, in accordance with facility
policy (on admission, readmission, quarterly, and with a significant change in condition). Check “Yes” or
“No” if the item reflects the resident’s assessment. If the answer is “yes” to three or more of the items listed
below, consider implementation of the “Skin Tear Prevention Protocol.”
Skin Tear Risk Assessment
Yes
No
Reduced mental status
History of skin tears
o
o
o
o
o
o
Dehydration
o
Self-abusive behavior
o
o
Poor nutritional status
Thin, translucent skin
Yes
No
Resistant to care
o
o
o
o
o
o
o
Bruises easily (If yes, total number of
bruises:__________)
o
o
o
o
Skin Tear Prevention Protocol To Be
Implemented
o
o
History of syncope or unsteady gait
History of aggressive behavior
Skin Tear Prevention Protocol
When the Skin Tear Risk Assessment identifies that the resident is at risk for skin tears, the nurse will review this protocol
and indicated pertinent interventions on the treatment record. The nurses on the unit, not the treatment nurse, manage
this protocol, which includes:
1. Provide covering for legs, such as long pants, heavy stockings, tube socks, or stockinet
2. Provide covering for arms, such as, stockinet, long sleeved shirts, or gowns.
3. Application of Kling for arms or legs ensuring no tape on skin.
4. Send inappropriate clothing home with the family so that it is not put on the resident by mistake. If the resident has no
family, put the clothing in storage with the resident’s name on it.
5. Re-evaluate the necessity of side rails and if still necessary pad the side rails on the bed. Care plan for potential
isolation due to the use of padded side rails.
6. Notify activities not to place the resident very close to another resident.
7. Use two staff members for all care performed as appropriate.
8. If the resident becomes combative or resists care, stop the care and return after the resident calms down. Try to identify
what triggered the behavior. Adjust the care plan as necessary to include potential interventions.
9. Provide lotion to the skin routinely.
10. Assess the resident’s overall skin condition on a weekly basis – mark completion of this task on the treatment record.
11. Maintain hydration for the resident.
12. Examine equipment (e.g. wheelchair, bed, bedrails) for sharp edges that could potentially harm the resident. Notify
maintenance if appropriate. Consult therapy in assisting with appropriate padding when necessary.
13. Notify Dietician to adjust diet as necessary.
Nurse Signature: _________________________________________ Date Protocol Initiated: __________________
Skin Tear Risk Assessment: page 2
Skin Tear Risk Assessment and Prevention Protocol—Audit
Related Federal Standard: “Quality of Care”
Audit Objectives:
To evaluate the application and use of the facility’s skin tear risk assessment.
To evaluate the application and use of the facility’s skin tear prevention protocol.
To identify that identified residents receive care based on the skin tear prevention protocol.
Resident Sample:
All residents in the facility who have received a risk assessment and residents that have been identified to be at
risk for developing skin tears.
Audit Sample Size:
_____ residents that were assessed for skin tear risk
_____ residents that were placed on the skin tear prevention protocol
Time Period of Evaluation: ________________________________________________ through: __________________
Commencement Date of Study: _____________________Expected Completion Date of Study: __________________
Criterion
No.
1
2
3
Audit Criteria
The Skin Care Risk Assessment is used to assess for risk
of skin tear:
a. Upon admission
b. Upon readmission
c. Each quarter
d. With a significant change in status
The Skin Tear Risk Assessment is complete:
a. Resident name
b. Total score is indicated
c. Indication if Skin Tear Protocol is to be implemented
d. Date assessment completed
e. Nurse’s signature
If Prevention Protocol was indicated, it was implemented:
a. Interventions were identified on the protocol form
b. Interventions were placed on treatment record
c. Interventions were identified on care plan
d. Implementation date is indicated
e. Nurse’s signature is present
Document available at www.primaris.org
Exceptions
Instructions for
Data Retrieval
None
Skin Care Risk
Assessment
None
Skin Care Risk
Assessment
Residents at risk Skin Care Prevention
for skin care
Protocol
MO-08-08-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare &
Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff
Care Center.
LTC Dehydration Risk Assessment
Resident Name:____________________________________________________ Date: __________________
Check all conditions that apply to this resident. The greater the number of items checked, the greater the risk for dehydration. Initiate a plan of care if necessary based on your findings.
Medical Conditions/History:
Medications:
o
Diabetes
o
CHF
o
CVA
o
Dementia
o
Depression
o
Major Psychiatric Disorder
o
Renal Disease
o
> 4 Chronic Conditions
o
≥ 4 medications
o
Diuretics
o
Laxatives
o
Steroids
o
ACE inhibitors
o
Psychotropics/antipsychotics
o
Antianxiolytics
o
Tricyclic Antidepressants or Lithium
History of:
o
Repeated infections
o
Dehydration
o
Malnutrition
o
Constipation
Intake Ability Status
Current Status:
o
Age ≥ 85
o
Female gender
o
Language/speech difficulties
o
Cognitive Impairment
o
Unable to request fluids
o
Unaware of thirst
o
Recent change in mental status
o
Any physical immobility
o
Recent change in ability to carry out ADLs
o
Restraints
o
Falling episodes
o
Urinary incontinence
o
Decreased urinary output
o
Constipation or diarrhea
o
Current fever and/or infection
o
Vomiting
o
Recent rapid weight loss (>3% / 30 days)
o
Draining wound
o
Lethargy/weakness
o
Increased combativeness/confusion
o
Readmission from > 1 day hospital stay
o
Lab/Studies involving NPO or dyes
o
Swallowing difficulties
o
Refuses fluids
o
Dislikes fluids/foods offered
o
Fluid restriction
o
Requires assistance to eat/drink
o
Poor eater (eats < 50% of each meal)
o
Holds food/fluid in mouth
o
Drools
o
Spits out food/fluid
o
Spills fluids
o
Tube fed
o
IV fluid therapy
Laboratory Abnormalities:
(or steady increase even if within normal range)
o
Urine Specific Gravity
o
Urine color dare yellow > 4
o
BUN/Creatinine > 20:1 -or­
o
 in BUN + stable Creatinine level
o
Serum Sodium
o
Serum Osmolality
o
Hematocrit > normal
o
BMI < 2 or > 27
Knowledge Issues:
o
Lack of understanding about fluid needs
o
Lack of understanding about causes of dehydration
o
Cultural barriers about hydration, reporting thirst, end
of life issues
Comments: _______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Nurse’s Signature:__________________________________________________________________________
Document available at www.primaris.org
MO-08-05-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do
not necessarily reflect CMS policy.
Comprehensive Admission Skin Assessment
Resident: _______________________________________________ Date:_____________________________
Perform a visual assessment of a resident’s skin upon admission. Report any areas of concern to the charge
nurse immediately. Forward any areas of concern to the next shift. Initiate a plan of care to address the
problem and alert the CNAs. Use this form to show the exact location and description of the abnormality.
Using the body chart below, describe and chart all abnormalities by number.
Indicate on the body chart any areas of concern:
A = Abrasion(s)
ST = Skin Tear(s)
B = Bruise(s)
SU = Stasis Ulcer(s)
PU = Pressure Ulcer(s)
SW = Surgical wound(s)
S = Scar(s)
O = Other
Narrative Note: Note site, length, width, depth, drainage, odor, pain and any other defining characteristics.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Nurse Signature: _______________________________________________________ Date: ____________________
Document available at www.primaris.org
MO-06-07-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare &
Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff
Care Center.
Licensed Nurse Weekly Skin Assessment
Resident: ______________________________________________________________ Date:____________________ Room #:_________________
This form should be completed weekly on all residents per facility policy. Any areas of skin requiring treatment should have a thorough record of
documentation in addition to this form located elsewhere in the chart per facility protocol. Check “Yes” or “No” if the item reflects the resident’s
assessment. If the answer is “yes” to 3 or more of the items listed below, consider implementation of the “Skin Tear Prevention Protocol.” Review
the care plan to ensure skin care is included as necessary.
If any questions are answered “yes,” indicate location on body outline with
number of question.
Weekly Skin Assessment
1
2
3
4
5
6
7
8
Any reddened areas that remain after 30 minutes of
pressure reduction? Comments: __________________
_____________________________________________
Any rashes? Comments: ________________________
_____________________________________________
Any bruises? Comments:________________________
_____________________________________________
Any open lesions, cuts, lacerations, or skin tears?
(Indicate even if being treated.) Comments: ________
_____________________________________________
Any blisters? Comments:________________________
_____________________________________________
Any open ulcers (indicate even if being treated.)
Comments: ___________________________________
_____________________________________________
Excessively dry or flaky skin? Comments:___________
_____________________________________________
Any edema? Location:__________________________
_____________________________________________
Yes
No
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Licensed Nurse Signature: _________________________________________________ Date: __________________
Document available at www.primaris.org
MO-08-09-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff Care Center.
Skin Monitoring: Comprehensive CNA Shower Review
Perform a visual assessment of a resident’s skin when giving the resident a shower. Report any
abnormal looking skin (as described below) to the charge nurse immediately. Forward any problems
to the DON for review. Use this form to show the exact location and description of the abnormality.
Using the body chart below, describe and graph all abnormalities by number.
Resident: _______________________________________________ Date:_______________________
Visual Assessment
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Bruising
Skin tears
Rashes
Swelling
Dryness
Soft heels
Lesions
Decubitus
Blisters
Scratches
Abnormal color
Abnormal skin
Abnormal skin temp (h-hot/c-cold)
Hardened skin (orange peel texture)
Other: _________________________
CNA Signature:_________________________________________________________ Date: ____________________
Does the resident need his/her toenails cut?
Yes
No
Charge Nurse Signature: ________________________________________________ Date: ____________________
Charge Nurse Assessment:___________________________________________________________________________
_________________________________________________________________________________________________
Intervention: ______________________________________________________________________________________
_________________________________________________________________________________________________
Forwarded to DON:
Yes
No
DON Signature: ________________________________________________________ Date: ____________________
Document available at www.primaris.org
MO-06-42-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare
& Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff
Care Center.
Skin Monitoring: Daily Skin Check
Skin checks are to be completed daily for residents. A good time to do them is during AM and
PM care and during bathing time. List the resident name, type and site (as listed below) of observed
impaired skin integrity.
Diagram Key
Types
Sites
• Bruises(B)
• Skintears(ST)
• Pressureulcers(PU)
• Scabs(S)
• Other(O)
• Ears,RTorLT(E)
• Shoulders(S)
• Arms(A)
• BackofHead(H)
• Coccyx(CO)
• Legs(L)
• Shin(SH)
• Knees(K)
• Feet(F)
• Heels(HE)
• Hands,front(HF)
• Hands,back(HB)
• Other(O)
Resident Name
E
E H E
E
S
A
A
S
A
A
CO
HF
L
L
HF
L
L
K K
SH SH
F F
Type
HE HE
Site
Staff Name: _____________________________________________ Completion Date:___________________
Document available at www.primaris.org
MO-08-43-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare &
Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Systems Investigative Audit: Pressure Ulcer Prevention/Treatment
Purpose:
To evaluate the decision-making process and adequacy of the facility’s process in the prevention of pressure ulcers and appropriateness of treatment protocols.
• NOTE:thefollowingauditcriteriaarebroad.Selectacurrentclinicalpracticeguideline(CPG),orutilizethefacilityassessmenttoolforpressure
ulcers to guide your detailed audit.
Criteria:
1. Residentisscreenedwithin24hoursofadmissionforriskofskin
breakdownusingastandardizedrisk-screeningtool.
2. Anappropriatepressureulcerpreventionortreatmentcareplanwas
putintoplacewithinthefirst24hoursofadmissionforallresidents
whetherhighorlowriskandaccordingtocurrentCPGs.
3. Skin/woundassessments/reassessmentweredoneatappropriate
intervalsaccordingtodeterminedlevelsofriskandcurrentCPGs,
• Fullskinassessmentatleastweeklywithdetaileddocumentation,
accordingtoCPGs,ofwoundcondition,ifpresent
• Atleastdailymonitorpressuresitesandareasofskinchanges
• Progressofwoundhealingisreassessedq2-4weeksandtreatment
plan re-evaluated if no evidence of progress noted
4. Thecareplanincorporatedthefollowingcareneedsaswellasall
identifiedriskfactors:
• Needsforturning/positioningwereidentified
• Positioning/pressurereliefproductneedswereidentifiedand
utilizedconsistentlyandproperly
• Nutritionassessmentwascompletedandidentifiedneeds
included in the care plan
• Individualizedskincareneedswereidentifiedandincludedinthe
care plan
• Interventionswereincludedfromalldisciplinesforeitherpressure
ulcer prevention or treatment
5. Careplaninterventionswereimplementedasindicated.
6. Careplanwasconsistentlyevaluatedandrevised,basedoncurrent
resident assessed needs.
7. Documentationofskincondition,interventionforriskfactors,
treatment of existing pressure ulcers and evaluation of effectiveness
wastimely,consistent,andfollowsrecommendedCPGs.
8. Anappropriatesystemforcommunicatingtoalldirect-carestaffskin
riskfactors,interventionsandchangesintheplanofcarewasinplace
and functioned properly.
9. Responsibilityandaccountabilitywasassignedforeachphaseofthe
pressureulcerprevention/treatmentprocess.
• Thosedesignatedasresponsibleandaccountableformonitoring
theprocessesofpressureulcerprevention/treatmentcarriedout
theirresponsibilitiesinatimelymanner
10.Policyandprotocolsareupdatedandcommunicatedtoallstaff
according to current clinical practice guidelines.
11.TheQA/CQIcommitteehadprocessesinplacetotrackandidentify
patternsandtodeterminetherootcauseofskinbreakdownevents.
• Identifiedsolutionsweresystem-oriented
• Contentofstaffeducationwasdeterminedbycompetency
evaluationsandidentifiedareasofweakness
12.Ifresidentself-determinationwasacontributingfactorinpressure
ulcerdevelopment,reasonablecounsel,educationandalternatives
wereprovided.
Systems Investigative Audit: Pressure Ulcer Prevention/Treatment: Page 2
Reviewer:______________________________________________
Chart 1
1.
Admission risk assessment completed with
appropriate tool
2.
Skin needs care plan was in place within 24
hrs of admission
3.
Assessments and reassessments done at
appropriate intervals
4.
Care plan incorporates all identified risk
factors
5.
Interventions are implemented as
indicated
6.
Care plan shows evidence of timely
revisions based on assessed resident needs
7.
Skin condition, interventions and
evaluation of interventions documented
8.
Staff demonstrates awareness/
understanding of care plan content.
9.
Accountability is evidenced by those
responsible for monitoring, assessment
and follow-up
Chart 2
Dateofreview: _____________________________
Chart 3
Chart 4
10. Skin policy/protocols are current &
followed consistently
11. QA/CQI meetings focus on root-cause
analyses
12. Resident/family education provided
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Chart 5
Chart 6
Comments
Pressure Ulcer Prediction, Prevention and Treatment Pathway
Step One: Assess Skin Condition
Resident is admitted or readmitted to SNF
Head-to-toe skin assessment (upon admission and weekly)
Does the resident have a pressure ulcer?
Yes
Pressure Ulcer Documentation
•
•
•
•
•
•
Length
Width
Depth
Location
Stage
Exudate
•
•
•
•
•
•
Tunneling
Necrosis
Granulation
Undermining
Sinus tracts
Pain
Report findings
to physician
No
Overall Skin Condition Documentation
•
•
•
•
Color
Temperature
Moles
Bruises
•
•
•
•
Incisions
Scars
Intact skin
Burns
Report anything
abnormal to physician
Obtain
treatment order from
physician
Obtain treatment
order from physician if
appropriate
Notify Family
Notify Family
Turn page
Go to Step 2
Turn page
Go to Step 2
Remember, if a patient is at risk or has a pressure ulcer, repeat Step One on a weekly basis.
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Pressure Ulcer Prediction, Prevention and Treatment Pathway
Step Two: Complete Risk Assessment to
Identify Risk Factors and Care Plan Interventions
Complete Skin Risk Assessment
At Risk?
Remember that those with a pressure ulcer are automatically at risk.
No
Repeat skin risk assessment at least every 90 days
and significant change or per facility protocol
Yes
Care Plan Actual Skin Problem
Yes
Does the resident have
a pressure ulcer?
No
Care Plan Potential Skin Problem
Complete Care Plan Problem Statement
Complete Care Plan Problem Statement
Skin integrity, impaired, actual as evidenced by (AEB) (Woundspecific description: Location, stage, and measurements)
related to (R/T) identified risk factors
Potential for impaired skin integrity, as evidenced by (AEB), risk assessment indicates
that the resident is at risk for skin breakdown related to (R/T) identified risk factors
Address Possible Risk Factors
Bed/Chair
Mobility
Possible Care Planning Interventions
Yes
Bed
• T/R schedule
• Pressure reducing/relieving device
• Therapy consult
Chair
• Repositioning schedule
• Pressure-relieving cushion
• Assessment of chair fit
No
Friction
and/or
Shear
Yes
Friction/Shear
• Padding to prevent skin contact
• Booties/heel protectors, elevate heels
• HOB in lowest position possible, unless contraindicated by medical condition
• Positioning devices
No
B/B
Incontinence
and
Moisture
Yes
Incontinence
• Peri care after each incontinence
• Clean as soon as possible after soiling
• Barrier cream
• Incontinent pads, incontinent briefs
Moisture
• Remove incontinence brief while
in bed
• Moisture barrier
No
Nutrition and body weight
Nutrition
and Body
Weight
Perform Step Two at least
every 90 days and with any
significant change. Adjust
care plan as needed.
Yes
No
Other
Residentspecific Risk
Factors
• Weekly weight
• Dietician consult
• Labs
• Food supplements
• Speech therapy
• Vitamin/medication supplements
• Hydration
• Feeding assistance
• Assessment for chewing and swallowing problems
Other
Yes
• Add any/all interventions related to identified specific risk factors
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Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Tissue Tolerance and Individualized Turning Schedule
Resident: ______________________________________________________________ Date:____________________ Room #:_________________
Recommended times for change in position are noted with desired position.
Codes: RS ( right side) LS ( left side) , B (back) OOB ( lift/shift in chair) W/C, HOB ( head of bed, raised seating) T (toileted)
When repositioning check after 30 minutes to see if the bony prominence is still red. Report to nurse.
Change every hour in W/C and at least ever 2 hours in bed. Do not raise HOB higher than 30 degrees unless directed by nurse.
Date
Time
Desired
position
Check back after
turned, red after 30
Actual
min? Indicate “no”
position or Location that is Desired
& initials
still red
position
Actual
position
& initials
Check back after
turned, red after 30
min? Indicate “no”
or Location that is
still red
Check back after
turned, red after 30
Actual
min? Indicate “no”
Desired position or Location that is
position & initials
still red
Desired
position
Actual
position
& initials
11:30 pm
/
/
/
/
1:30 am
/
/
/
/
3:30 am
/
/
/
/
5:30 am
/
/
/
/
7:30 am
/
/
/
/
9:30 am
/
/
/
/
11:30 am
/
/
/
/
1:30 pm
/
/
/
/
3:30 pm
/
/
/
/
5:30 pm
/
/
/
/
7:30 pm
/
/
/
/
9:30 pm
/
/
/
/
Initial
Name
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Initial
Name
Initial
Name
Initial
Name
MO-08-13-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff Care Center.
Check back after
turned, red after 30
min? Indicate “no”
or Location that is
still red
Managing Tissue Loads
Appropriate Patient Positioning
Key
Yes/No Decisions
Interventions
Multiple
large, truncal Stage III
or IV ulcers?
Yes
No
Able to
keep ulcer off
surface?
No
Use device that moves air
across skin
Yes
Yes
Patient at
risk for additional
ulcers?
No
No special surface needed
Yes
Skin
moisture
problem?
No
Multiple
turning spaces
available?
Yes
Static device
No
Dynamic overlay or
mattress
Yes
Patient
bottoms
out?
Patient
bottoms
out?
Yes
No
No
Ulcer
healing
properly?
No
Ulcer
healing
properly?
Yes
Yes
Monitor
No
Low air-loss bed
Yes
Ulcer
healing
properly?
No
Ulcer
healing
properly??
Air-fluidized bed
No
Reference: Quick Reference for Clinicians No. 15
Page 10 Developed by AHCPR
Reevaluate plan of care
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Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Yes
Monitor
Support Surfaces: Characteristics and Considerations
Specialty Beds
Air-fluidized bed (also known as a “bead bed” or “sand bed ”)
Product Characteristics: This is a bed frame containing silicone-coated beads incorporated in Gortex® covering. When air
is pumped through the beads, they behave like a liquid, creating air and fluid support. The resident “floats” on a sheet with one
third of the body above the surface and the remainder of the body immersed in the warm, dry, fluidized beads. When bed is
turned off, the surface becomes firm to allow for repositioning. Helps manage copious wound drainage or incontinence by
absorbing fluids into bed of silicone beads. Although there is some evidence that air-fluidized beds enhance pressure ulcer
healing rates, surface interface pressure remains sufficiently high to occlude capillary perfusion. Occipital and heel ulcers have
been reported to develop in patients while on an air-fluidized bed (Parish & Witkowski, 1980).
Considerations:
• Not recommended for mobile patients, patients with pulmonary disease or patients with unstable spine
• Continuous circulation of warm, dry air may dehydrate patient or desiccate wound bed
• Bed may get too hot or make room hot
• Head of bed cannot be raised; semi-Fowler’s position achieved by using foam wedges or movable sling-type device
• Coughing less effective in mobilizing secretions
• Leakage of beads may irritate the eyes and respiratory track and make floor slippery
• Width of bed may preclude care to obese patients or patients with a contracture
• Height of bed makes some nursing care difficult, and a step is needed to facilitate care
• Transfer of patient out of bed is difficult
• Bed is heavy and not easily transferable
• Some patients become disoriented or complain of feeling weightless while on surface
• Dependent drainage of catheters may be compromised because the patient is immersed in the bed
• Sharp objects may damage the surface
• Size and weight may be too large for use in home setting
•
Set up and maintenance provided by company
Low air-loss bed
Product Characteristics: A bed frame with a series of connected air-filled pillows that can be calibrated for varying
amounts of pressure to provide maximum pressure reduction for residents. Dry air flow between the patient and bed
surface helps control moisture and heat buildup and prevents maceration and friction. Some models are designed to
counteract the effects of immobility on pooling of respiratory secretions and urinary stasis by providing oscillation therapy.
Other models feature kinetic therapy (rotating slowly side to side), although this is limited to a 20-degree rotation and does
not have the same effect as manually rotating the resident side-to-side.
Considerations:
• Head and foot of bed can be raised and lowered
• Transfers in and out of bed easily accomplished
• Portable motor available to maintain inflation during bed transfers.
• Motor may be noisy
• Proper inflation essential to maintain effectiveness
• Sharp objects may damage the surface
Support Surfaces: Characteristics and Considerations: page 2
•
•
Bed surface is slippery; patients may slide down or out of bed with being transferred
Heels need to be “floated” to totally relieve pressure
•
Set up and maintenance provided by company
Dynamic Overlays
Alternating air-filled overlay
Product Characteristics: Air is pumped through overlay chambers at regular intervals to provide cyclical pressure
changes, creating a low-pressure and a high-pressure area. These surfaces constantly change pressure points and create
pressure gradients that enhance blood flow. Cells with larger diameter and depth produce greater pressure relief over the
body. A cell depth of not less than 3 inches is recommended.
Considerations:
• Surface is easy to clean
• Assembly required
• Sensation of inflation and deflation may bother patient
• Electricity required
• Motor may be noisy
• Excessive or sudden surface movement may disturb sleep
• Sharp objects may damage the surface
• Bed surface is slippery; patients may slide down or out of bed with being transferred
• Heels need to be “floated” to totally relieve pressure
Static Overlays
Foam Overlay
Product Characteristics: A foam surface applied over the surface of an existing hospital mattress. The following
characteristics of foam influence the effectiveness of the overlay: base height, density and indentation load deflection (ILD).
Base height refers to the height of the foam from the base to where the foam ridges begin and should be 3 to 4 inches to
be effective in reducing pressure. Density refers to the weight per cubic foot and reflects the foam’s ability to support the
person’s weight. Foam densities of 1.3 to 1.6 pounds per cubic foot are generally effective in supporting an average size
adult. ILD is a measure of the firmness of the foam. It describes the foam’s compressibility and conformability. It also
indicates the ability of the foam to distribute the mechanical load. Measurement of ILD is expressed as the number of
pounds required to indent a sample of foam with a circular plate to a depth of 25% of the thickness of the foam. An ILD of
approximately 30 pounds is recommended. Optimal support and conformability of foam is achieved when the relationship
between 60% ILD and 25% ILD is 2.5 or greater (Krouskop & Garber, 1987; Whittemore, 1998).
Considerations:
• Plastic protective sheet is usually required for incontinent patients
• Foam may trap perspiration and be hot
• Washing removes flame-retardant coating
• One-time charge, no reoccurring charges
• No set up or maintenance fees
• Cannot be punctured by needle or metal traction
• Light weight
Support Surfaces: Characteristics and Considerations: page 3
•
•
•
•
•
•
•
•
Requires no maintenance
No electricity required to operate
May be hot and trap perspiration
Foam has a limited life
Lack of firm edge creates unsure surface when patient transferring on and off surface
Heels need to be “floated” to totally relieve pressure
Must be discarded when wet from drainage or incontinence
Adds height to the bed
Air Overlay
Product Characteristics: Interconnected bubble-like cells that are inflated with an air blower to an appropriate pressure
level. Optimum air level is defined as 1 inch or more of uncompressed support surface between bony area of the resident’s
body and the caregiver’s hand when placed under the support surface. Cells with larger diameter and depth produce
greater pressure relief over the body. A cell depth of 3 in. or greater is recommended.
Considerations:
• Easy to clean
• Low maintenance
• Repair of some products is possible
• Durable
• Can be damaged by sharp objects
• Requires regular monitoring to determine proper inflation and need for reinflation
• Heels need to be “floated” to totally relieve pressure
• Adds height to bed
• Lacks a firm edge, so transfer on and off surface may be difficult
Water Overlay
Product Characteristics: A vinyl chamber that can be filled with water to appropriate level to distribute body weight
evenly over the entire supporting surface. Recommended depth is 3 in. or greater. Some models contain a baffle system to
control motion effects.
Considerations:
• Readily available in the community
• Easy to clean
• Requires water heater to maintain comfortable water temperature
• Fluid motion makes procedures difficult (e.g. positioning)
• Patient transfers may be difficult
• Inadvertent needle punctures will create leaks
• Maintenance is needed to prevent microorganism growth
• Surface is heavy
• Cannot raise head of bed unless mattress has compartments
• Can be overfilled (causing too firm a surface) or underfilled (decreasing pressure reducing benefit)
Support Surfaces: Characteristics and Considerations: page 4
Gel Overlay
Product Characteristics: A pad constructed of Silastic, silicone or polyvinyl chloride. Lack air-flow for moisture
control and friction control is variable depending on the surface of the gel. Recommended depth for effective
support is 2 in. or more. Gel filled pads are particularly useful in wheelchairs.
Considerations:
• Low maintenance
• Easy to clean
• Multiple-patient use
• Impermeable to punctures with needles
• Surface is heavy
• Expensive purchase price
• Heels need to be “floated” to totally relieve pressure
• Research on effectiveness is limited
•
Some surfaces may be slippery; patient may slide down or out of bed during transfers
Replacement Mattress
Product Characteristics: Mattress made of foam and gel combinations or layers of different foam densities.
Some models have replaceable foam shapes and some have a replaceable foam core. Other replacement
mattresses contain a series of air-filled chambers covered with a foam structure. All models are covered with
a comfortable, water-repellent, bacteriostatic cover that can be maintained with routine cleaning. Mattresses
with foam should be antimicrobial and have appropriate foam ILD with high resiliency. Evidence is increasing
that replacement mattresses are superior to standard hospital mattresses and may be more effective than some
overlays (Vyhlidal, et al., 1997).
Considerations:
• Reduce use of overlay mattresses
• Reduce staff time
• Do not add height to mattress
• Provide certain level of pressure reduction automatically
• Multiple-patient use
• Easy to clean
• Use standard hospital linens
• Low maintenance
• Initial expense is high
• Some mattresses have removable sections which may be misplaced
• May not control moisture
• Potential for excessive delay in using other support surface
• No objective method for determining when or if product loses effectiveness
• Life of product is not known
Support Surfaces: Characteristics and Considerations: page 5
Additional References:
Hess, CT: Wound care, Springhouse, Pennsylvania, 2000, Springhouse Corporation.
Krouskop TA, Garber SL: The role of technology in the prevention of pressure sores, Ostomy & Wound Management, 16:45,
1987.
Maklebust J, An Update on Horizontal Patient Support Surfaces. Ostomy & Wound Management, 45, No 1A (suppl) 70S to
77S, 1999.
Maklebust J, Sieggreen M: Pressure ulcers guidelines for prevention and management, Pennsylvania, 2001, Springhouse
Corporation.
Parish IC, Witkowski JA: Clinitron therapy and the decubitus ulcer: preliminary dermatologic studies, Dermatology,
19:517, 1980.
Vyhlidal S et al: Mattress replacement or foam overlay? A prospective study on the incidence of pressure ulcers, Applied
Nursing Research, 10(3):111, 1997.
Whittemore, R. Pressure reduction support surfaces: A review of the literature. JWOCCN, 25:6-25. 1998.
Source: National Nursing Home Improvement Collaborative Coordinated by Qualis Health, Learning Session Two,
January 2004
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MO-08-48-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Pressure Ulcers: Treatment Product Categories
Pressure ulcers require consistency in treatment to promote healing. Use this list that includes the major types of products to ensure your nursing
center carries an appropriate range of materials. Nursing staff then can choose the most effective dressing type based on wound stage, characteristics
and potential concerns.
Treatment
Products
Description
Appropriate
Wound Stage
Characteristics
Concerns
Polyurethane Film
Tegaderm™
Op-site◊
EpiVIEW™
others
Adhesive and transparent.
Stages 1-2
Occlusive and waterproof
Retains water
Impermeable to bacteria & contamination
Promotes moist wound healing
Nonabsorbent
May be changed every 3 to 7 days
May be used as a secondary dressing over a more
absorbent product
Should not be used with moderate to
heavy exudate wounds
May macerate surrounding skin
Hydrocolloid
DuoDERM®
Replicare®
Comfeel®
Others
Adhesive wafers composed of gelatin,
pectin, and carboxymethyl-cellulose
Stages 1-4
Occlusive and waterproof
Retains moisture
Impermeable
Promote moist wound healing
Moderately absorbent
Easy to apply
Should not be used with heavy exudate
wounds
Should not be used if infection is present
May have odor upon removal
May be difficult to remove
Hydrogels
Hypergel®
Carrasyn®
DuoDERM®
Elasto-Gel Sheet™
SoloSite◊
Others
Glycerin or water based gels, wafers,
sheets, and impregnated gauze with or
without adhesive borders
Stages 2-4
Non-adherent
Fills dead space
Semi-occlusive
Promotes moist wound healing
Easy to apply & remove
Minimally absorbent
Retains moisture and rehydrates wound
May macerate surrounding tissues
Secondary dressing required
Daily application required unless applied
with adhesive borders
Dries out easily
Risk of candidiases
Foams
PolyMem®
Allevyn◊
Lyofoam®
Others
Hydrophilic polyurethane foam, available
in wafers, sheets, and pillow with foam
covering
Stages 2-4
Non-adherent
Easy to apply and remove
Highly absorbent
Can be used on various levels of exudate
Additional fixation is required unless has
an adhesive border
Alginates
SORBSAN™
KALTOSTAT®
Algisite M◊
Others
Non woven fibers containing calcium
sodium salts of alginic acid, available in
pads or ropes
Stage 2 wounds with
a lot of exudate
Stages 3-4
Non-adherent
Promotes moist wound healing
Can be used on infected wounds
Should not be used on dry or low exudate
wounds, the wound may get dehydrated
Secondary dressing required
Typically requires daily application
Pressure Ulcers: Treatment Product Categories, Page 2
Treatment
Products
Description
Antimicrobial
ACTICOAT◊
SilvaSorb®
IODOSORB◊
ALLEVYN Ag◊
Optifoam AG®
Others
Ionic silver and cadexomer iodine that
provides sustained antimicrobial barrier to
multiple bacteria including strains of MRSA
and VRE. Can be found in different types
of products including alginates, gels and
polyurethane film
Collagen
Biostep◊
Prisma®
Promogran®
Puracol®
Others
Gauze, Dry or Wet
Appropriate
Wound Stage
Stage 2 wounds
when antimicrobial
treatment is needed
Stages 3-4
Characteristics
Concerns
Manages bacterial burden
Non-cytotoxic
Do not use with a resident with a known
sensitivity to silver.
Iodine products should be avoided if
known sensitivity, or thyroid disorder.
Do not use in conjunction with topical
antibiotics
Collagen provides the matrix for the body’s Wounds that have
tissue structure. Stimulates wound healing stalled in healing
Can be found in different delivery systems: Chronic wounds
dried collagen matrix, hydrogel with
collagen, hydrogel base.
Promotes new tissue growth
Wound debridement
Pulls wound edges together
Do not use on dry wounds
Do not use with patients sensitive to
bovine products
Woven natural cotton fibers,; non woven
rayon and plastic blends; available in pads
and rolls, sterile and non sterile
May be dampened with saline or water
Inexpensive
Facilitates moist to dry debridement
Non-adherent when used as a wet to moist dressing
Minimal to moderate absorbency
Moist to dry debridement can be painful,
damaging healthy tissue
Woven gauze is abrasive
Requires frequent changes
Packing may harden, causing further
pressure injury
Stages 2-4, especially
if wound is deep or
has tissue that needs
debridement
Related Wound Treatments
Treatment
Products
Vacuum Controlled
Assisted Closure
(V.A.C.)
KCI VAC®
Engenex™
EZCARE◊
V1STA◊
Description
System that uses controlled negative
pressure to help promote wound healing.
VAC system pulls infectious materials and
excess interstitial fluid from the wound
Indications
Pressure ulcers
Traumatic wounds
Post op-dehisced &
surgical wounds
Contraindications
Concerns/Precuations
Malignancy
Active bleeding
Untreated osteomyelitis
Difficult hemostasis
Unexplored fistulas into the body cavity or to an organ Anticoagulant therapy
Necrotic tissue with eschar in the wound abed
Exposed arteries or veins
Uncontrolled pain
** Brands are listed for reference purposes only. We do not recommend use of one brand over another.
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Health and Human Services, and adapted from LHCR. The contents presented do not necessarily reflect CMS policy.
Nutritional Wound Healing Guidelines
Policy:
This sample procedure is to help enhance the healing of pressure ulcers by the use of nutritional intervention
whenever possible. These are guidelines only and individual patient and resident needs must be taken into
consideration before implementation.
Procedure:
The nursing department reports all pressure ulcers and their stage to food and nutrition services.
• The available dietician is contacted and reviews each case to make an individualized nutrition care plan.
• Food and nutrition services may implement the following interventions, based upon the stage of resident’s
pressure ulcers. Note that vitamin and mineral supplementation would require a physician’s order.
» Stage 1: 4 Vitamin C-rich food, high protein afternoon snack and a daily MVI with minerals
» Stage 2: Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day and MVI with
minerals daily
» Stage 3: 8 oz. Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day, high-protein
snacks twice a day and MVI with minterals
» Stage 4: 8 oz. Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day, high-protein
snacks three times a day and MVI with minerals
•
Other nutritional considerations:
•
•
•
•
•
•
•
•
Think about other options to enhance nutritional status, such as:
» Increase eggs, milk, meat and cheese for additional HBV protein
» Add protein powder to foods
» Add other foods high in Vitamin C if the resident or patient dislikes orange juice
» Use Arginaid powder in place of Arginaid Extra if the patient is obese
Continue nutritional interventions until wound has been healed for two weeks
Avoid zinc supplementation for more than two months at a time
Goal caloric intake is 30-35 kcal per kg or BMR x 1.5 stress factor x 1.2 (bed) or 1.3 (out of bed)
Goal protein intake with no renal considerations is as follows:
» Stage 1: 1.2-1.4 g. per kg.
» Stage 2: 1.4-1.6 g. per kg.
» Stage 3: 1.6-1.8 g. per kg.
» Stage 4: 1.8-2 g. per kg.
Goal of fluid is 30-35 ml. fluid per kg.
If on chronic antibiotic use, give yogurt or lactobacillus supplements
If patient/resident has a compromised gut (intestinal mucosal atrophy or malabsorbtion from malnutrition,
10-20 mg. of glutamine supplementation should be considered
Note: 8 oz. Arginaid Extra provides the following: 10 g. protein, 250 calories, 20 mg. zinc, 1,000 IU vitamin A, 250 mg. vitamin C; MVI with minerals usually contain
the following amounts: 15 mg. zinc, 3,500 IU vitamin A, 60 mg. vitamin C, 18 mg. iron and 2 mg. copper
Document available at www.primaris.org
MO-08-46-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Selected Characteristics of Support Surfaces
Selected Characteristics for Classes of Support Surfaces
Support Devices
Performance characteristics
Air-fluidized Low Air-loss
Alternating
Air
Static Flotation
(air or water)
Foam
Standard
Mattress
Increased support area
Yes
Yes
Yes
Yes
Yes
No
Low moisture retention
Yes
Yes
No
No
No
No
Reduced heat accumulation
Yes
Yes
No
No
No
No
Shear reduction
Yes
?
Yes
Yes
No
No
Pressure reduction
Yes
Yes
Yes
Yes
Yes
No
Dynamic
Yes
Yes
Yes
No
No
No
High
High
Moderate
Low
Low
Low
Cost per day
Reference: Quick Reference Guide for Clinicians, No. 15, page 11. Developed by the Agency for Healthcare Research and Quality (AHRQ).
Chair Support Surfaces
Support Surface
Characteristics
Cost
Concerns
Foam Cushion
• Provides some pressure reduction,
depending upon the thickness of the
foam (a thickness of no less than four
inches is recommended)
• Resident still requires repositioning at
least every hour
Low Cost
• After laundering, this surface is no longer
useful for pressure reduction. A slip cover
that can be separately laundered keeps
the cushion clean and dry
Gel Cushion
• Reduces pressure by spreading pressure
across the contact surface
• Does not replace repositioning
Low to
Moderate
Cost
• Pressure reduction depends on the
cushion’s condition (watch for breaks
in the integrity of the cushion, which
renders this product ineffective)
• Do not attempt to mend any breaks in
the cushion
Air-filled Cushion
• Reduces pressure by evenly distributing
weight
• Cells fill with air and deflate as pressure is
applied. Does not replace repositioning
High Cost
• Compromised integrity can render this
product ineffective. An ineffective airfilled cushion should be replaced
Document available at www.primaris.org
MO-08-51-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
SBAR: Skin Care Instructions
S
B
Situation
Resident Name: ______________________________________________________ Age:___________ Admit Date: _________________
Admitting physician/consulting physician: ___________________________________________________________________________
Diagnosis/reason for admission: ____________________________________________________________________________________
Treatment plan: _________________________________________________________________________________________________
Background (check all that apply)
Past medical history: _____________________________________________________________________________________________
Allergies: _______________________________________________________________________________________________________
Diet type: ___________________________________________ q NG/G-tube feedings q TPN/PPN q Ostomy/drains q Foley
Medication
A
Assessment (check all that apply)
q Pressure ulcer present q Precautions:___________ q Completely immobile q Limited mobility q Fully mobile
q Incontinent q Impaired sensation q Alert/oriented q Confused q Lethargic/unresponsive q Photos taken
Braden Score:_______ Decubitus Key
q High Risk
q Low Risk
q No Risk
Date
R
Medication
Site Diagram
Stage I: Red/skin intact
Stage II: Superficial breakdown
Stage III: Skin breakdown Sub Q involved
Stage IV: Skin breakdown. Muscle/bone exposed
*Do no stage if base of wound not visible
Site #
Stage
Size (in cm)
Front
Right
Back
Left
Left
Right
Description (color, drainage, odor, sloughing, eschar, undermining)
Recommendation (check all that apply)
Pressure Ulcer Prevention Measures
Pressure Ulcer Management
q Keep clean and dry
q Avoid diaper/brief use
q Apply cleanser/barrier lotions to ________ every ____ hours
q Apply Nystatin powder to _____________ every ____ hours
q Use special bed/mattress (specify type): __________________
q Turn and reposition patient every ______ hours
q Use chair cushion (specify type): ________________________
q Elevate heels
q Use heel protectors/heel lift
q Use elbow protectors
q Dietary/nutrition consult
q Other:______________________________________________
q Ulcer treatment: _____________________________________
q Dressings (specify type and frequency): __________________
___________________________________________________
q Wound vac: _________________________________________
q Consider Foley catheter:_______________________________
q Odor control:________________________________________
q Dietary/nutrition consult
q Other:______________________________________________
___________________________________________________
Comments: _____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Assessment and recommendations completed by (signature)__________________________________ Date: __________________
Treatment protocol approved by (signature) ________________________________________________ Date: __________________
Document available at www.primaris.org
MO-08-52-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
What happens if I get a pressure ulcer?
Pressure ulcers are serious problems that can lead to
pain, slower recovery from health problems and possible
complications such as infection. By working with your health
care team to lower your risk factors, most pressure ulcers can
be prevented.
Ask your health care
provider if you are at risk
for pressure ulcers, and
work together to develop a
plan to prevent them.
P
U
ressure
lcer
revention
P
PUP protects your
skin
MO-08-44-PU June 2008 This material was prepared by Primaris, a Medicare Quality Improvement Organization, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The
contents presented do not necessarily reflect CMS policy.
Reduce your risk of getting pressure ulcers. Get your family and health care team involved in prevention.
What is a pressure ulcer? A pressure ulcer, also known
as a pressure or bed sore, is an area of the skin that has damage
caused by unrelieved pressure. Pressure ulcers begin as reddened
areas but can damage skin and muscles if not treated properly.
Where are they found on the body? Pressure ulcers
typically occur in bony areas of the body that sustain pressure
when lying or sitting in bed for long periods of time (shoulders,
elbows, hips, buttocks and heels).
Who gets pressure ulcers? Anyone confined to a bed
or chair, who is unable to move, has loss of sensation, bowel
or bladder control, poor nutrition or has lowered mental
awareness is at risk of getting a pressure ulcer.
What can I do to prevent pressure ulcers?
• Keep moving and change your position frequently. If you
are unable to move yourself, make sure the staff helps you
reposition regularly.
• Look after your skin. Keep skin and bedding dry and
moisturize dry skin.
• Look for skin’s warning signs. Let the staff know if your
skin stays red longer than thirty minutes, feels warm or
firm to the touch and/or is blistered or broken.
• Reduce friction. Don’t pull or drag yourself across
sheets or push or pull with your heels. Avoid repetitive
movements, such as scratching your foot on the sheets.
• Eat a balanced diet. Ask your nurse or health care
professional for a proper nutritional plan.
Stages
Pressure Ulcer Definition and Stages
D E F I N ITI O N
A pressure ulcer is localized
injury to the skin and/or
underlying tissue usually
over a bony prominence,
as a result of pressure, or
pressure in combination
with shear and/or friction.
A number of contributing
or confounding factors are
also associated with pressure
ulcers; the significance
of these factors is yet
to be elucidated.
Pressure ulcers are staged
using the system at right.
P R E S S U R E U LC E R STAG E S
(SUSPECTED) DEEP TISSUE INJURY
STAGE III
Purple or maroon localized area of discolored intact
skin or blood-filled blister due to damage of underlying
soft tissue from pressure and/or shear. The area may
be preceded by tissue that is painful, firm, mushy,
boggy, warmer or cooler as compared to adjacent tis­
sue.
Full thickness tissue loss. Subcutaneous fat may be vis­
ible but bone, tendon or muscle are not exposed.
Slough may be present but does not obscure the depth
of tissue loss. May include undermining and tunneling.
Further Description: Deep tissue injury may be diffi­
cult to detect in individuals with dark skin tones.
Evolution may include a thin blister over a dark wound
bed. The wound may further evolve and become cov­
ered by thin eschar. Evolution may be rapid exposing
additional layers of tissue even with optimal treatment.
STAGE IV
STAGE I
Intact skin with non-blanchable redness of a localized
area usually over a bony prominence. Darkly pig­
mented skin may not have visible blanching; its color
may differ from the surrounding area.
Further Description: The area may be painful, firm,
soft, warmer or cooler as compared to adjacent tissue.
Stage I may be difficult to detect in individuals with dark
skin tones. May indicate “at risk” persons (a heralding
sign of risk).
STAGE II
Partial thickness loss of dermis presenting as a shallow
open ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured serumfilled blister.
Further Description: Presents as a shiny or dry shal­
low ulcer without slough or bruising.* This stage
should not be used to describe skin tears, tape burns,
perineal dermatitis, maceration or excoriation.
*Bruising indicated suspected deep tissue injury.
National Pressure Ulcer Advisory Panel
1255 Twenty-Third Street NW, Suite 200
Washington, DC 20037
T: 202-521-6789
F: 202-833-3636
www.npuap.org
Further Description: The depth of a stage III pres­
sure ulcer varies by anatomical location. The bridge of
the nose, ear, occiput and malleolus do not have sub­
cutaneous tissue and stage III ulcers can be shallow. In
contrast, areas of significant adiposity can develop
extremely deep stage III pressure ulcers. Bone/tendon
is not visible or directly palpable.
Full thickness tissue loss with exposed bone, tendon or
muscle. Slough or eschar may be present on some
parts of the wound bed. Often include undermining
and tunneling.
Further Description: The depth of a stage IV pres­
sure ulcer varies by anatomical location. The bridge of
the nose, ear, occiput and malleolus do not have sub­
cutaneous tissue and these ulcers can be shallow. Stage
IV ulcers can extend into muscle and/or supporting
structures (e.g., fascia, tendon or joint capsule) making
osteomyelitis possible. Exposed bone/tendon is visible
or directly palpable.
UNSTAGEABLE
Full thickness tissue loss in which the base of the ulcer
is covered by slough (yellow, tan, gray, green or
brown) and/or eschar (tan, brown or black) in the
wound bed.
Further Description: Until enough slough and/or
eschar is removed to expose the base of the wound,
the true depth, and therefore stage, cannot be deter­
mined. Stable (dry, adherent, intact without erythema
or fluctuance) eschar on the heels serves as “the
body’s natural (biological) cover” and should not be
removed.
This staging system should be used only to describe pressure ulcers. Wounds from other causes, such as
arterial, venous, diabetic foot, skin tears, tape burns, perineal dermatitis, maceration or excoriation should not be
staged using this system. Other staging systems exist for some of these conditions and should be used instead.
Updated 02/2007 Copyright © 2007
Pressure Ulcer Classifications
Suspected Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood-filled
blister due to damage of underlying soft tissue from pressure and/or shear.
The area may be preceded by tissue that is painful, firm, mushy, boggy,
warmer or cooler as compared to adjacent tissue.
Further description
Deep tissue injury may be difficult to detect in individuals with dark skin
tones. Evolution may include a thin blister over a dark wound bed. The wound
may further evolve and become covered by thin eschar. Evolution may be
rapid exposing additional layers of tissue, even with optimal treatment.
Stage 1
Intact skin with non-blanchable redness of a
localized area usually over a bony prominence.
Darkly pigmented skin may not have visible
blanching; its color may differ from the
surrounding area.
Further description
The area may be painful, firm, soft, warmer or
cooler as compared to adjacent tissue. Stage I may
be difficult to detect in individuals with dark skin
tones. May indicate “at risk” persons (a heralding
sign of risk).
Stage II
Partial thickness loss of dermis presenting as a
shallow open ulcer with a red pink wound bed,
without slough. May also present as an intact or
open/ruptured serum-filled blister.
Further description
Presents as a shiny or dry shallow ulcer without
slough or bruising.* This stage should not be
used to describe skin tears, tape burns, perineal
dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury
Pressure Ulcer Classifications
Stage III
Full thickness tissue loss. Subcutaneous fat may
be visible but bone, tendon or muscle are not
exposed. Slough may be present but does not
obscure the depth of tissue loss. May include
undermining and tunneling.
Further description
The depth of a stage III pressure ulcer varies by
anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have subcutaneous
tissue, and stage III ulcers can be shallow. In
contrast, areas of significant adiposity can develop
extremely deep stage III pressure ulcers. Bone/
tendon is not visible or directly palpable.
Stage IV
Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be
present on some parts of the wound bed. Often
include undermining and tunneling.
Further description
The depth of a stage IV pressure ulcer varies by
anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have subcutaneous
tissue and these ulcers can be shallow. Stage IV
ulcers can extend into muscle and/or supporting
structures (e.g., fascia, tendon or joint capsule)
making osteomyelitis possible. Exposed bone/
tendon is visible or directly palpable.
Unstageable
Full thickness tissue loss in which the base of the ulcer is covered by slough
(yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the
wound bed.
Source: National Pressure Ulcer Advisory Panel, Pressure Ulcer Stages Revised, February 2007.
Permission to use granted to Primaris, the Quality Improvement Organization for Missouri.
Documentation and Measuring
13
A
This ruler is intended for use as a reference only. To prevent infection, do not use this ruler to measure an actual wound.
Measure the length “head to toe” at the longest point (A) and the
width at the widest point (B). Measure the depth (C) at the deepest
point of the wound. All measures should be in centimeters.
14
15
Measuring Wounds
B
11
12
C
10
Using a clock format, describe the location and extent of
tunneling (sinus tract) and/or undermining.
3
8
9
sample
9
12
Undermining
A narrow channel of
passageway extending into
healthy tissue
Tunneling wound which
begins directly under the
wound edge.
1
CM
If the wound has many landmarks, you may want to trace it
before measuring.
2
3
4
Tunneling/Sinus Tract
5
The head of the patient is 12:00, the patient’s foot is 6:00
6
7
6
Pressure ulcer documentation includes
Wound location
Stage
Size
• Length
• Width
• Depth
Tunneling/Sinus Tract
Undermining
Necrotic Tissue
• Slough
• Eschar
Granulation
Pain
Exudate/Drainage
• Amount
• Color
• Odor
Description of
Surrounding Tissue
Support Surface
Wound edges
• Round
• Rolled
• Extended
Note the following skin characteristics
•
•
•
•
Color
Temperature
Moles
Bruises
•
•
•
•
Incisions
Scars
Intact
Burns
MO-08-49-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for
Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services, and adapted from LHCR. The contents presented do not necessarily reflect CMS policy.
Pressure Ulcers: CNA Knowledge & Attitude Survey
We are interested in your individual answer. Please check the box to indicate “True” or “False” for each of the following statements.
Position Title: _____________________________________________________________________________
Department: _______________________________Shift (check one): o Days o Evenings o Nights
Pressure Ulcers: CNA Knowledge and Attitude Survey
True
False
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
13. A bed ridden resident will not fully recover from a pressure ulcer without surgery.
o
o
Pressure ulcers are often viewed as a sign of poor care being provided by the
nursing staff.
o
o
o
o
o
o
1. Identification and reporting of reddened or open areas of skin are part of my job.
2. Pressure ulcer prevention is part of my job.
3. Pressure ulcers should only be documented by RN or LPN staff members.
4. Immobility is a cause of pressure ulcers.
5. Incontinence is a cause of pressure ulcers.
6. Poor dietary intake is a cause of pressure ulcers.
7. Chronic illness is a cause of pressure ulcers.
8. Poor circulation is a cause of pressure ulcers.
9. Pressure ulcers are part of the aging process.
10. Pressure ulcers can be prevented by proper positioning of residents.
Pressure ulcers begin with a reddened area of the skin that does not disappear
after pressure is relieved.
Residents who have had a pressure ulcer in the past are more likely to develop
12.
one in the future.
11.
14.
15. Pressure ulcers lower a resident’s self-esteem.
16. Pressure ulcers can occur on any area of the body.
Pressure Ulcers: CNA Knowledge & Attitude Survey, page 2
CNA Knowledge and Attitude Survey Results
A Guide to Action
Ask staff to complete the CNA Pressure Ulcer Knowledge and Attitude Survey. Then, use the following as an
answer key and a guide to action. You’ll notice that particular answers may be “True” for some staff and “False”
for others. This sheet will show how you might revise overall nursing home practices to improve staff knowledge
and residents’ care.
Questions 1 & 2
All nursing home clinical staff should have identification, assessment, prevention, care and documentation of
pressure ulcers identified as a part of their job duties. If your staff felt this statement was “False,” this may be an
area you could focus on for additional training.
Non-clinical staff’s answers may vary between “True” and “False.” If you have non–clinical staff who feel that
prevention is not part of their job, consider additional training. It is important for all staff to recognize ways
they can identify potential problems and inform appropriate clinical staff. Ideas for improvement:
• Explain how and why you’re committed to pressure ulcer prevention and treatment
• Describe you home’s overall pressure ulcer plan
• Describe each team member and family member’s role in pressure ulcer prevention assessment and treatment
Question 3
This question addresses pressure ulcer documentation. All staff is responsible for noting information as a
part of the general pressure ulcer plan of care. Leaders must instruct how and where that information will be
documented on the resident’s record. Non-clinical staff may answer “False,” but you need a process for nonclinicians to report their observations as well, ensuring this information is documented. Ideas for improvement:
• Define pressure ulcer documentation guidelines for all disciplines.
• Offer training on sharing work responsibilities among disciplines. For example, activities staff must
reposition resident while attending activities and document this for staff sharing, dietary staff must know the
resident with a pressure ulcer cannot sit up to eat
• Identify pressure ulcer tools to increase documentation consistency throughout the facility and within
clinical staff. For example: ulcer measurement guide, bedside turning schedule, staging guidelines or exudate
documentation
Questions 4, 5, 6, 7, 8 and 12
These question reference risk factors for pressure ulcer formation. Immobility, poor nutrition, incontinence and
circulatory conditions are all risk factors.
If your facility’s surveyed staff felt any of these statements were “False,” it may indicate that the pressure ulcer
risk factors are not well known or their importance is not well understood. You may want to identify if one
group of employees or employees in general need information regarding risk factors and the role they play in
pressure ulcer formation. Questions to ask staff:
• What are the identified pressure ulcer risk factors?
• How do risk factors contribute to the formation of pressure ulcers?
• When are residents assessed for risk factors in your facility?
• What effect do risk factors have on residents’ plan of care?
Pressure Ulcers: CNA Knowledge & Attitude Survey, page 3
• Who is responsible for identification and care planning for residents with identified risk factors?
• Why is this important?
Question 9
This question addresses a common misconception. Pressure ulcers are not part of the normal aging process.
Although loss of skin elasticity and thinning of the skin are normal with aging, pressure ulcer formation is not.
If most of your staff answered “True” to this survey question, you need to provide them with information about
the normal aging process, including:
• How the factors of the normal aging process contribute to the risk for pressure ulcer formation.
• What your facility is doing to address the care associated with the elderly. For example, nutritional and
activity programs, support groups, association with community support group.
• Your facility’s efforts to communicate with other health care facilities that you have direct interaction with,
i.e. referring hospitals, senior citizen groups, physician’s offices, home health agencies.
Question 10
This question addresses the role of proper positioning in pressure ulcer prevention. If the lower extremity
were positioned with proper support to keep pressure off the heel, an ulcer due to pressure on the heel would be
prevented.
If staff felt positioning did not contribute to pressure ulcer prevention, as noted with a “False” answer, consider:
• Instruction on and demonstration of basic positioning techniques.
• Reviewing your home’s resident care plans to address proper positioning and repositioning, i.e. turning
schedule, pressure reduction techniques, devices available at your facility to reduce pressure load.
• Reviewing of the etiology of pressure ulcer formation with staff, such as prolonged pressure reducing the
blood flow to the capillaries causing tissue damage.
Question 11
This question addresses pressure ulcer development. Pressure ulcers begin with a reddened area of the skin
that does not disappear after the pressure is relieved. This is identified as a Stage I pressure ulcer. A response
of “False” to this question indicates your staff doesn’t have a good understanding of pressure ulcer formation.
Consider the following actions:
• Provide all staff with common consistent definitions of pressure ulcer stages, such as guidelines from the
National Pressure Ulcer Advisory Panel.
• Adopt standard facility procedures for describing, measuring and evaluating pressure ulcers.
• Provide consistent tools – such as measurement guides and an assessment scale – throughout the home for
staff to use consistently
• Review and adapt your pressure ulcer plan of care
Question 13
This question identifies the misconception that a bed-ridden resident’s pressure ulcer requires surgery to heal.
Improved wound care products and pressure reduction devices have greatly increased the healing of pressure
ulcers without surgical interventions. If staff responded “True,” to this statement, consider:
• Demonstrating and discussing newer pressure-reduction products available to assist with wound healing and
discussing clinical indications
Pressure Ulcers: CNA Knowledge & Attitude Survey, page 4
Question 14
If clinical staff answered “True” to this question they may need further education and information about why
pressure ulcers occur. Consider offering training on:
•
Non-compliancewithpressureulcerplanofcare
•
Diseaseprogression
•
Poornutritionalintake
•
Otherpressureulcerriskfactors
For non-clinical staff additional information may include:
•
Trainingontheetiologyofpressureulcerformation
•
Reviewingtheroleofnon-clinicalstaffinpressureulcerpreventionandtreatment
•
Reviewingriskfactors
•
Informationontheirspecificroleinthecareprocessasitrelatestopressureulcers.
Question 15
If staff answered “True” to this statement, it indicates they understand the emotional impact a physical condition
can have on residents’ self-esteem. Pressure ulcers may limit the independence of the resident. They may also
contribute to a resident feeling ‘sick’ and dependent on others for care. Additionally, many pressure ulcers
occur in areas of the body that are emotionally uncomfortable for people to deal with, such as the buttocks.
Dignity may be compromised if the resident feels embarrassed or ashamed over having a pressure ulcer. Family
members may be angry at the facility or the resident. This could add to feelings of inadequacy the resident may
already be experiencing.
If anybody answered “False,” offer education to all staff, families and volunteers about pressure ulcers effect on
residents’ psychosocial well-being as well as their physical discomfort.
Question 16
Pressure ulcers may occur on any part of the body exposed to unrelieved pressure that decreased the flow of
blood a sufficient length of time to cause underlying tissue damage. A “False” answer to this question may
indicate that your staff does not understand the etiology of a pressure ulcer. Although pressure ulcers generally
are noted over boney prominences of the body, they can occur at any location where unrelieved pressure is
noted. Educational intervention may include:
• Pressure ulcer definition and staging guidelines
• Proper positioning and repositioning techniques
• Proper use of pressure reduction devices
• Frequent reinforcement that pressure ulcer prevention and treatment is everybody’s responsibility
Document available at www.primaris.org
MO-08-15-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not
necessarily reflect CMS policy.