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Kansas Health Care Association Disclaimer presents The information presented herein is provided for educational and informational purposes only. It is for the attendees’ general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state. The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies shall not be liable for any errors or omissions in this information. Pressure Ulcers F314, MDS 3.0, M‐Section and More Pamela Scarborough PT, DPT, MS, CDE, CWS, CEEAA Director of Public Relation & Education American Medical Technologies 1 2 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Notations NPUAP National Pressure Ulcer Advisory Panel AMDA American Medical Directors Association CMS SOM Centers for Medicare & Medicaid Services State Operations Manual MDS 3.0 Minimum Data Set, 3.0: M‐Section Regulatory F314 F309 Guidelines Standards of Practice Evidenced Based Framing Your Pressure Ulcer Prevention & Care Program Clinical Pearl Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 3 Pressure Ulcer Resources Recommended to be Used by Surveyors for LTC NPUAP AMDA WOCN Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 4 State Operations Manual • CMS State Operations Manual (SOM) ‐ a guide for what you do in clinical practice • SOM reflects current evidence based practice • Taken from current wound care research and practice • Prevention of PrUs gets lots of attention from CMS • Can find and download at: http://www.cms.gov/CFCsAndCoPs/Download s/som107ap_pp_guidelines_ltcf.pdf – NPUAP/EPUAP Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline – 2014 – NPUAP.org – Quick Reference Guide free – Fee for full version of Guideline • AMDA Clinical Practice Guidelines for Pressure Ulcers‐ 2011 or 800.876.2632 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. to order www.amtwoundcare.com MDS 3.0 M‐Section 5 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 6 1 Intent of F314 CMS‐Surveyors • Often times the surveyor sees a facility acquired pressure ulcer as a failure of your systems and care for pressure ulcer prevention • The ONLY way to show the surveyor differently is in the quality of your documentation • Well organized PrU prevention program reduces facility acquired PrU…only unavoidable PrU occur • Caregivers competent • Limited exclusively to PrUs • Other wounds (arterial, venous, diabetic, etc.) are grouped under F309, the regulation for Quality of Care – Critical for physicians to accurately perform a differential diagnosis of chronic wounds • Recommend review of accepted definitions to prevent confusion between surveyors and clinical staff in terms of documentation Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • F‐309 ‐ used to site wounds not pressure ulcers • Arterial • Venous insufficiency Timely Interventions • Diabetic neuropathic foot ulcers • Within F‐309 is § 483.25 Quality of Life mandate… – “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well‐being, in accordance with the comprehensive assessment and plan of care.” Prevention of PrU – F309 ‐ Covers requirements for pain management during wound care Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Modify Interventions 10 Risk Assessment Key for Prevention Identify Individuals @ Risk Identify & Eval Risk Factors PrU Prevention & Healing Implement interventions stabilize, reduce / remove risk factors Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 9 Critical Steps Monitor impact of interventions 8 Prevention of Other Wounds PrU Risk Assessment Tool Early detection: At Risk Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 7 Identify & Eval Changes in Condition Identify & Eval factors removed or modified 11 Identify and document risk factors Identify pre‐existing signs (skin trauma, DTI) Assess and document pain Include Resident Assessment Instrument (RAI) Identify resident with: – multi‐system organ failure – end‐of‐life condition – refusal of care and treatment • Address factors that have been identified as having an impact on the development, treatment and/or healing of pressure ulcers…(ex. steroids) Copyright © 2014 Gordian Medical, Inc. • Document ALL dba American Medical Technologies. 12 • • • • • Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division www.amtwoundcare.com 2 Prevention Risk Assessment NPUAP Recommendation • Risk assessment • NPUAP goes on to discuss that the Risk Assessment Policy 1. Be established in ALL healthcare settings 2. That each facility educate health professionals on how to achieve an accurate and reliable risk assessment 3. And that there be documentation of all risk assessments – central component of clinical practice – identify susceptible patients – target appropriate interventions‐prevent pressure ulcers • NPUAP recommends – risk assessment policy – risk assessment practice • Structured approach • Use risk assessment scale in combination with Do you have a PrU risk assessment policy and procedure in your facility? – comprehensive skin assessment, assessment of activity, mobility – include clinical judgment Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 13 14 Specific Considerations for Pressure Ulcer Risk NPUAP Statement • “Caution: Do not rely on a total risk assessment tool score alone as a basis for risk based prevention. • Risk assessment tool subscale scores and other risk factors should also be examined to guide risk‐based planning.” Advanced Age Skin Moisture Friction & Shear General Health Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 15 (DM) Refusal of care Drugs (Steroids) Moisture Exposure Risk Factors for Developing Pressure Ulcers (Incontinence) Cognitive Impairment Previous Stg 3 or 4 PrU Increased Shear Decreased Mobility Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Sensory Perception Body Temperature Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 16 Number 1 Reason for Pressure Ulcers Comorbid conditions Nutrition Issues Perfusion & Oxygenation Nutritional Indicators 17 •Decreased Mobility in bed and chair Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 18 3 Mobility NPUAP Mobility NPUAP 1.2. Consider the impact of mobility limitations on pressure ulcer risk. (Strength of Evidence = B; Strength of Recommendation = ) • Being bedfast or chairfast are usually described as limitations of activity. A reduction in an individual’s frequency of movement or ability to move is usually described as having a mobility limitation. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 19 Skin Assessment • Mobility and activity limitations can be considered a necessary condition for pressure ulcer development. • In the absence of these conditions, other risk factors should not result in a pressure ulcer. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 20 Skin Assessment • Part of PrU risk assessment screening policy • Educate professionals ‐ comprehensive skin assessment includes identifying: – blanching response – localized heat – edema – induration (hardness) • Inspect skin regularly for signs of redness in persons at risk of pressure ulceration‐CNAs – The frequency of inspection may need to be increased if any deterioration in overall condition Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 1.3. Complete a comprehensive risk assessment for bedfast and/or chairfast individuals to guide preventive interventions. (Strength of Evidence = C; Strength of Recommendation = ) 21 Recognize & Document Suspected Deep Tissue Injury • Inspect for any skin discoloration – Note: darker skin tones my not show any change in color • Assess sensation – (pain and itching) • Palpate for any changes in temperature (warm or cold) or consistency (firm or boggy) Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 22 Pressure Ulcer Risk Assessment Screening Frequency • Admission • Weekly for first 4 weeks after admission for each resident at risk • Quarterly • Whenever a change in cognition or functional ability • “This deep tissue damage could lead to unavoidable Stage 3 or 4 PrU or progression of a Stage 1 PrU to an ulcer with eschar within days” Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. Copyright © 2012 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com www.amtwoundcare.com 23 • CMS says resident’s risk for PrU development may increase due to: – acute illness – condition change (eg, upper respiratory infection, pneumonia – exacerbation of underlying congestive heart failure) • These residents may require additional evaluation. 24 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 4 M0100 Determination of Pressure Ulcer Risk Prevention & Risk Assessment CMS considers facility acquired PrU to be a sentinel event in a resident who had been assessed as being at low risk for a PrU CMS Sentinel Event • The only residents who are at high risk are those who have • impaired transfer or bed mobility • are comatose • malnourished • any other resident is at low risk (until proven otherwise) Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • Reflects multiple approaches for determining a resident’s risk for developing a PrU A. Presence or indicators of PrUs B. Assessment using a formal tool C. Physical examination of skin and/ or medical record D. Z. None of the above Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 25 Low Blood Pressure Braden Parameters Sensory Perception 1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No Impairment Mobility 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitations • Systolic BP below 100 mmHg – Activity Moisture 1. Constantly Moist 1. Bedfast 2. Chairfast 2. Very Moist 3. Walks 3. Occasionally Occasionally Moist 4. Walks Freq. 4. Rarely Moist Nutrition Friction & Shear 1. Very Poor 1. Problem 2. Probably 2. Potential Inadequate Problem 3. Adequate 3. No Apparent 4. Excellent Problem Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com associated with PrU development • Hypotension may shunt blood flow away from the skin to more vital organs • Decreasing the skin tolerance for pressure by allowing capillaries to close at lower levels of interface pressure • Water hose Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 27 Underscoring Risk Severity on Braden Scale Scores • • • • 26 28 Low Blood Pressure Value That is NOT Mentioned on Braden Critical Consideration!!! Mild Risk = 15 ‐ 18 Moderate Risk = 13 ‐ 14 High Risk = 10 – 12 Very High Risk = 9 or below • Systolic BP below 100 mmHg – associated with PrU development **If other major risk factors are present (e.g., age, fever, poor dietary intake of protein, diastolic pressure <60, and/or hemodynamic instability), advance to next level of risk. Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • Hypotension may shunt blood flow away from the skin to more vital organs • Decreasing the skin tolerance for pressure by allowing capillaries to close at lower levels of interface pressure • Water hose 29 Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 30 5 Ensure Your Braden Done Correctly!!! Predispose to intense pressure Affect tissue tolerance Predispose to intense pressure Predispose to intense pressure Affect tissue tolerance Affect tissue tolerance Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 31 F‐314 Surveyor Guidance: Risk Factors for Developing PrUs Risk Assessment and POC • Risk factors for PrU include, but are not limited to: • Comorbid conditions (e.g. DM, end‐stage renal disease, thyroid disease) • Drugs that may affect ulcer healing (e.g. steroids) • Exposure of skin to urinary or fecal incontinence • History of a healed Stage III or IV PrU**** • Impaired or decreased mobility or functional ability • Increase in friction or shear • Moderate to severe cognitive impairment • Resident refusal of some aspects of care & treatment • Undernutrtion, malnutrition, & hydration deficits Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 33 Nutrition for PrU Prevention • Screen/ assess the nutritional status of everyone at risk for pressure ulcers in each health care setting. – Use a valid, reliable and practical tool – Have a nutritional screening policy in place along with recommended frequency of screening for implementation • Refer each person with nutritional and pressure ulcer risk to a registered dietitian • Refer to a multidisciplinary nutritional team – registered dietitian, a nurse specializing in nutrition, physician, speech/language therapist, occupational therapist, when necessary a dentist Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 32 35 • Risk assessment • Document and address each risk in the resident’s plan of care 34 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Nutrition F314 Triggers F327 Nutrition Tag • Adequate nutrition and hydration assessment and provided • Weight loss monitoring • Nutritional goals for prevention and healing of PrU • Protein ‐ 1.2‐1.5 gm/kg body weight daily Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 36 6 F314 & Repositioning • Repositioning: – Common, effective intervention • person with PrU • person at risk for developing PrU – Critical for immobile residents (or those dependent upon staff for repositioning ) • Resident care plan for those at risk of friction/shearing with repositioning may require the use of lifting devices • Positioning the resident on an existing pressure ulcer should be avoided Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com – Adds pressure to compromised tissue – May impede healing 37 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 38 General Reposition Recommendations for All Individuals HIGH RISK AREAS Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 39 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com General Recommendations Heels‐Prevention 2014 Updates on Repositioning 5. Use a foam cushion under the full length of the calves to elevate heels. (Strength of Evidence = B; Strength of Recommendation = ) • Pressure can relieved by elevating the lower leg and calf from the mattress by placing a foam cushion under the lower legs, or by using a heel suspension device that floats the heel. • Pillows placed under the full length of the calves to elevate heels may be appropriate for short‐term use in alert and cooperative individuals. The knee should be in slight flexion to prevent obstruction of the popliteal vein and caution should be taken to place no pressure on the Achilles tendon. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 1. Reposition all individuals at risk of, or with existing pressure ulcers, unless contraindicated. (Strength of Evidence = A; Strength of Recommendation = ) • Repositioning of an individual is undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body and to contribute to comfort, hygiene, dignity, and functional ability. 2. Consider the condition of the individual and the pressure redistribution support surface in use when deciding if repositioning should be implemented as a prevention strategy. (Strength of Evidence = C; Strength of Recommendation = ) • Regular positioning is not possible for some individuals because of their medical condition, and an alternative prevention strategy such as providing a high‐specification mattress or bed may need to be considered. 40 41 1. Inspect the skin of the heels regularly. (Strength of Evidence = C; Strength of Recommendation = ) • Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that the heels are free of the surface of the bed. (Strength of Evidence = C; Strength of Recommendation = ) • Ideally, heels should be free of all pressure — a state sometimes called ‘floating heels’. 1.1. Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. (Strength of Evidence = B; Strength of Recommendation = ) • Heel suspension devices are preferable for long term use, or for 42 individuals who are not likely to keep their legs on the pillows. Copyright © 2014 ‐ AMT Education Division 7 Heels Con’t. 2. The knee should be in slight (5° to 10°) flexion. (Strength of Evidence = C; Strength of Recommendation = ) • There is indirect evidence that hyperextension of the knee may cause obstruction of the popliteal vein, and this could predispose an individual to deep vein thrombosis (DVT 3. Avoid areas of high pressure, especially under the Achilles tendon. (Strength of Evidence = C; Strength of Recommendation = ) • 3.1. Use a foam cushion under the full length of the calves to elevate heels. (Strength of Evidence = B; Strength of Recommendation = ) • Pillows or foam cushions used for heel elevation should extend the length of the calf to avoid areas of high pressure, particularly under the Achilles tendon. Flex the knee slightly to avoid popliteal vein compression and increased risk of DVT. 43 Repositioning for Treating Existing Heel Pressure Ulcers 4. Apply heel suspension devices according to the manufacturer’s instructions. (Strength of Evidence = C; Strength of Recommendation = ) 5. Remove the heel suspension device periodically to assess skin integrity. (Strength of Evidence = C; Strength of Recommendation = ) Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 44 CMS & Heels 1. Relieve pressure under the heel(s) with Category/Stage I or II pressure ulcers by placing legs on a pillow to ‘float the heels’ off the bed or by using heel suspension devices. (Strength of Evidence = B; Strength of Recommendation = ) 2. For Category/Stage III, IV and unstageable pressure ulcers, place the leg in a device that elevates the heel from the surface of the bed, completely offloading the pressure ulcer. Consider a device that also prevents footdrop. (Strength of Evidence = C; Strength of Recommendation = ) • Pressure on Category/Stage III, IV, and unstageable heel pressure ulcers should be completely offloaded as much as possible. Elevation of the heel on a pillow is usually 45 inadequate. • Important to reduce pressure over heel and elbows • Pillows used to support the entire lower leg may effectively raise the heel from contact with the bed Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 46 REPOSITIONING TECHNIQUES REPOSITIONING TECHNIQUES • Use 30‐degree tilted side‐lying position – alternately; right, back, left side • Prone if individual can tolerate; – medical condition allows • Avoid postures that increase pressure – 90‐degree side‐lying – Semi‐recumbent • Avoid pressure / shear forces – Use transfer aids – Lift—don’t drag • Avoid positioning directly on medical devices • Avoid positioning on bony prominences with existing pressure ulcers or non‐blanchable erythema • Continue to turn and reposition regardless of support surface used • Do not use ring ‐ or donut‐shaped devices • Do not apply heating devices Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Heels Con’t • Who is teaching this to the CNA? • How are you monitoring repositioning in your facility? 47 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 48 8 Seating Considerations REPOSITIONING TECHNIQUES • Select posture acceptable for the resident • Posture that minimizes pressures and shear • Place the feet on footstool or wheelchair footrest when feet do NOT reach the floor • Limit time spent in chair without pressure relief • Sitting in bed – Avoid head‐of‐bed elevation – Avoid slouched position • places pressure and shear on the sacrum and coccyx • Limit head‐of‐bed elevation to 30⁰ – resident on bed‐rest – unless contraindicated by medical condition Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 49 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 50 WHAT IS A SUPPORT SURFACE? REPOSITIONING DOCUMENTATION • Per the NPUAP, a support surface is a specialized device for pressure redistribution designed for management of tissue loads, micro‐climate, and/or other therapeutic functions • E.g., any mattresses, integrated bed system, mattress replacement, overlay, or seat cushion, or seat cushion overlay. • Record repositioning regimes • Frequency and position adopted • Evaluation of outcome of repositioning regime Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 51 52 HOW SUPPORT SURFACES WORK PRESSURE REDISTRIBUTION • The ability of support surface to distribute load over contact areas of body Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 53 • Immersion and envelopment reduce tissue stress • Increasing the contact area between the support surface and individual’s body • Allowing for pressure redistribution Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 54 9 F314 & Support Surfaces; Pressure Redistribution Group 1 Group 2 • Match a device’s potential therapeutic benefit with the resident’s specific situation Group 3 – Multiple ulcers – Limited turning surfaces – Ability to maintain position • Effectiveness is based on their potential to address – 4‐inch convoluted foam pads – Gel pads – Air fluidized beds – Low loss air mattresses – Individual resident’s risk – Resident’s response to the product – The characteristics and condition of the product CMS SUPPORT SURFACE GROUPS Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • Examples of these surfaces or devices include: Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 55 56 CMS: Unavoidable Pressure Ulcers F314 CMS: Avoidable Pressure Ulcers F314 • Resident developed a pressure ulcer even though the facility: – Evaluated the resident’s clinical condition and risk factors – Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice – Monitored and evaluated the impact of the interventions – Revised interventions as appropriate • Resident developed a pressure ulcer and the facility DID NOT DO one or more of the following: – Evaluate the resident’s clinical condition and pressure ulcer risk factors – Define and implement interventions that are consistent with resident needs, goals, and recognized standards of practice – Monitor and evaluate the impact of the interventions – Revise the interventions if appropriate Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 57 Questions? Summary • Awareness is first step in prevention!!! • Implement care consistent with best practice and standard of care • Prevention and early intervention are critical so be proactive with skin assessment and risk assessment for pressure ulcers • Implement interventions in the plan of care that are specific to the resident and his/her clinical condition/s – i.e. an INDIVIDUALIZED care plan that is well documented, followed, reassessed and documented again Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 58 59 Let’s take a BREAK!!! 60 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 10 Moisture Associated Skin Damage Urinary + Fecal Incontinence Other Skin Issues that Confuse Pressure Ulcer Identification, Reporting and Treatment Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 61 REVISED: M1040H MASD • Moisture associated skin damage (MASD) is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate and perspiration. • It is characterized by inflammation of the skin, and occurs with or without skin erosion and/or infection. • MASD is also referred to as incontinence‐associated dermatitis and can cause other conditions such as intertriginous dermatitis, periwound moisture‐associated dermatitis, and peristomal moisture‐associated dematitis. Provision of optimal skin care and early identification and treatment of minor cases of MASD can help avoid progression and skin breakdown. • Often mistaken for stage 2 pressure ulcers 63 62 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Medical Device‐Related Pressure Ulcers Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 64 M0210 Unhealed Pressure Ulcers, M‐5 Coding Tips: • Oral Mucosal ulcers caused by pressure should not be coded in Section M. • These ulcers are captured in item L0200C, Abnormal mouth tissue. • Mucosal ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 65 Diabetic Neuropathic Foot Ulcers Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 66 11 Neuropathic Ulcer Appearance Neuropathic Ulcers • Ulcers develop due to repeated trauma or pressure with the associated tri‐neuropathy • Calluses lead to high pressure points • Develop due to altered musculoskeletal biomechanics and atrophy of underlying fat pad • Foot deformities common 67 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • Location: Plantar surface, toes, bony prominence • Pale pink, red • Periwound callus/ hyperkeratotic tissue • Slight to minimal drainage • Often round in shape • Pain may be absent with neuropathy • Pulses may be present, bounding or diminished 68 M1040B Diabetic Foot Ulcers Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com M1040B Diabetic Foot Ulcers • Do NOT include pressure ulcers that occur on residents with diabetes mellitus here. • For example, an ulcer caused by pressure on the heel of a diabetic resident is a pressure ulcer and not a diabetic foot ulcer. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 69 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 70 Practice Point • There is confusion around wounds on lower extremity in patients/residents with DM • These wounds are often mis‐categorized as “diabetic wounds” • In reality often these are wounds due to pressure related to immobility… • PAD and DM are contributing comorbidities, causing the skin to be more susceptible to pressure injury • Correct DX critical to initiate appropriate POC Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 71 Pressure Ulcers Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 72 12 Shear Forces NPUAP Pressure Ulcer Definition NPUAP: 2009 “A pressure ulcer is localized injury to the skin and/or underlying tissue, usually over a bony prominence that results from pressure (including pressure associated with shear).” Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 73 • Primary effects of shear occur at deep fascial level of tissues over bony prominences • Manifests clinically as large area of undermining which extends circumferentially • Vascular occlusion is enhanced if shear and pressure are together Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Depth of Tissue Destruction Partial Thickness Wounds Depth of Tissue Injury • Limited to epidermis & upper portion of dermis • Heals by regeneration • No scar tissue • No granulation tissue • No slough MDS 3.0 • • • • Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 75 Stage 2 PrU MASD Early venous insufficiency Skin tears 76 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Depth of Tissue Destruction Full‐thickness Wounds Category/Stage I Extends through epidermis & dermis May involve subcutaneous tissue, muscle or bone May have granulation tissue May have slough or eschar 74 – 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. Stage 3 & 4 PrU Arterial Diabetic foot ulcers Surgical dehiscence Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. http://npuap.org/pr2.htm (accessed March 2010) 77 dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 78 13 Category/Stage II Category/Stage I • This area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. • May indicate “at risk” persons (a heralding sign of risk). Copyright © 2014 Gordian Medical, Inc. • dba American Medical Technologies. www.amtwoundcare.com http://npuap.org/pr2.htm (accessed March 2010) • 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. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 79 Category/Stage III Category/Stage II • Presents as a shiny or dry shallow ulcer without slough or bruising.* This Category/ Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. • *Bruising indicates suspected deep tissue injury. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 81 Category/Stage III http://npuap.org/pr2.htm (accessed March 2010) • 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. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 82 Category/Stage IV • Depth varies by anatomic location. • The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue so Category/ Stage III ulcers can be shallow. • Areas of significant adiposity can have extremely deep Category/Stage III pressure ulcers. • Bone/tendon is not visible or directly palpable. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 80 • 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. http://npuap.org/pr2.htm (accessed March, 2010) Copyright © 2014 Gordian Medical, Inc. 83 dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 84 14 Category/Stage IV Unstageable : Depth Unknown • Depth varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. • Category/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. • New from NPUAP 9/12 • Cartilage position statement 85 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Unstageable Pressure Ulcers 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. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 86 Unstageable Heels • Three types to differentiate • Number of these unstageable pressure ulcers present upon admission/ reentry Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com http://npuap.org/pr2.htm (accessed March 2010) 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. NOTE: Document the clinical rational if stable eschar is removed 87 M0300E Unstageable Non‐Removable Dressing Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 88 M0300F Unstageable Slough and/ or Eschar • Known but not stageable related to coverage of wound bed by slough and/ or eschar • Known but not stageable because of the non‐removable dressing • Full thickness tissue loss • Base of ulcer covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 89 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 90 15 MO300G Unstageable Suspected Deep Tissue Injury (sDTI) • DTI may present as a pale, waxy white area in light‐ skinned people • Or a lighter patch of skin surrounded by abnormally darker areas in dark‐skinned people that shows no change in color when the capillary refill is tested discolored intact skin Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • (From Farid K. Applying observations from forensic science to understanding the development of pressure ulcers. Ostomy Wound Management 2007;53(4):26‐44.) Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 91 92 M1200 Skin and Ulcer Treatments1 Wound Care Interventions Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 93 General Principles Of Wound Care 94 A Few Words About Gauze • Permeable to bacteria • Off loading of pressure sites • Debridement of necrotic tissue • Prevention / treatment of infection • Obliteration of dead space • Absorption of exudate • Maintenance of moist environment • Protection and insulation • Nutrition & hydration support Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com – – – – 64 layers Airborne release Will NOT prevent bacterial contamination 3x Higher infection rate • Frequency of change – Fibers • Pain 95 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 96 16 Wound Care Interventions CMS‐F314: “Some facilities may use “wet to dry gauze dressings” or irrigation with chemical solutions to remove slough. The use of wet‐to‐dry dressings or irrigations may be appropriate in limited circumstances, but repeated use may damage healthy granulation tissue in healing ulcers and may lead to excessive bleeding and increased resident pain.” Manage Bioburden Debridement Cellular Biology Bioengineered Tissue NPUAP: Topical or Systemic Treatments Avoid use of gauze dressings for clean, open pressure ulcers because they are labor‐intensive to use, cause pain when removed if dry, and lead to desiccation of viable tissue if they dry. Pressure Redistribution Electrical Stimulation 97 Negative Pressure Hyperbaric Oxygen Copyright © 2014 Gordian Medical, Inc. Other Biophysical Agents dba American Medical Technologies. www.amtwoundcare.com 98 Biophysical Agents (Con’t) F314‐ DRESSINGS & TREATMENTS • A facility should be able to show that its document treatment protocols are based upon current standards of practice • Are in accord with the facility’s policies and procedures • And these policies and procedures are developed with the medical director’s review and approval (F501) • Electrical Stimulation • Acoustic Energy (Ultrasound) – High Frequency US – Low Frequency US • Contact • Non‐contact • Negative Pressure Wound Therapy • Hydrotherapy: Whirlpool & Pulsatile Lavage • Hyperbaric Oxygen Therapy (HBOT) • UV Light Do treatments with these products meet the “current standards of practice”? Courtesy of H. Loehne, PT, DPT, CWS 100 99 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • Does your facility have a functional wound assessment form or process (EMR)? Wound Assessment Documentation Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Tight Blood Glucose Control PDGF Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Dressings Inflammation 101 Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 102 17 F314 Interpretative Guidelines Pain Stage Dressings/ treatment (NPUAP) Pressure Ulcers Monitor Healing Infections (PUSH) Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 103 What Else Should Be Assessed? Drainage Periwound • History of prior ulcer and presence of current ulcer, previous treatments, or surgical interventions that increase risk for additional pressure ulcers Etiology Initial Wound Assessment • The pressure ulcer(s) at each dressing change Undermining Tunnel / Tract • Potential complications such as fistula, abscess, osteomyelitis, bacteremia, cellulitis and cancer Copyright © 2013 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Location Edges • Factors that impede healing status such as co‐morbid conditions and medications 105 104 Shape Wound Bed Copyright © 2013 Gordian Medical, Inc. Size Tissue Destruction Pain dba American Medical Technologies. www.amtwoundcare.com 106 Location Date Wound Identified Describe location anatomically correctly using current medical terminology Specific Terms Recurrence = Recidivism Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 107 Less Specific Terms R‐ischium R‐buttock R‐lateral malleolus R‐ankle L‐trochanter L‐hip Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 108 18 F314 ‐ Assessment & Treatment of PrU(s) See Page 2 of Wound Assessment Form Location • Document in reference to head, front or back • Commonly used terms – Proximal, distal – Superior, inferior – Medial, lateral – Anterior, posterior – Dorsal, plantar Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • Each existing pressure ulcer be identified • Whether present on admission or developed after admission • Factors that influenced the PrU development • Potential for development of additional ulcers • Factors causing deterioration of the pressure ulcer(s) be assessed and addressed • New pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers 109 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 110 111 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 112 Complicating Factors Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Measurement Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 113 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 114 19 Wound Measurement: Size = L x W x D Depth: Distance from visible surface to deepest point in wound base not covered with necrotic tissue Insert moistened sterile cotton swab Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 115 NOTE: Do not record depth if not able to see TRUE base of wound. Use unstageable designation. Copyright © 2014 Gordian Medical, Inc. 116 dba American Medical Technologies. www amtwoundcare com Wound Measurement Wound Measurement Undermining Tunneling Tissue destruction that occurs to the underlying intact skin adjacent to the wound margins. Formation of a “shelf” of healthy, intact tissue over an area of dead space and/or necrotic tissue. A single pathway that may extend in any direction Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Shelf under edge of wound 117 118 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com QUANTIFYING WOUND EXUDATE Exudate Status None/Dry Scant/ Small/ Minimal Moderate Reasons drainage may increase: • Infected • After sharp or surgical debridement • When using collagenase PS: Drainage drives dressing decisions. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 119 Large/ Heavy Copious/ Very Heavy Indicators: Based on a 24‐hour observation period Wound bed is dry; there is no visible moisture and the primary dressing is unmarked; dressing may be adherent to wound. Small amounts of fluid are visible when the dressing is removed; the primary dressing may be marked up to 25%, but strikethrough (or saturation through the dressing) is not occurring; in many cases, this is the goal of exudate management. Wound bed glistens. Routine dressing changes fully control the exudate. Routine and appropriate dressing changes show that the drainage has met the dressing’s absorptive ability without saturating or leakage; may cover 25%‐75% of the dressing. Dressings are saturated with changes at routine intervals; exudate is uncontrolled and freely expressed. More than 75% of the dressing is covered by drainage. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. 120 www.amtwoundcare.com Adapted from the Association for the Advancement of Wound Care Quality of Care Wound Glossary Copyright © 2014 ‐ AMT Education Division 20 Wound Bed Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Reporting Most Severe Tissue Type for Pressure Ulcers 1 Epithelial Tissue 2 Granulation Tissue 3 Slough Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 121 4 All Granulation Tissue is NOT Created Equal Healthy granulation tissue Eschar 122 Unhealthy, friable granulation tissue in infected wound Hypergranulation tissue Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 123 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Document Necrotic Tissue Describe Amounts and Locations in Wound Bed Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 125 124 Pain Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 126 21 Wound Related Pain Experiences CMS and Wound Related Pain Chronic Wound Pain • F314 • Pain, if present: nature and frequency (e.g., whether episodic or continuous); • Absence of manipulation • May be continuous/intermittent Cyclic Wound Pain Noncyclic Wound Pain Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 127 F314, F309 Assessment and Documentation of Wound Related Pain to Include: • Periodic acute wound pain • Regular repetitive treatments (i.e. dressing change) • Provoked by more sporadic procedures (i.e. sharp debridement) Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 128 Describe Wound Edges / Periwound • Location • Duration • Character (intensity and radiation) • Frequency Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 129 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 130 Treatment Plan NPUAP.org Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 131 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 132 22 F314 Interpretative Guidelines Therapeutic Goals Example 483.25(c) Based upon the assessment and the resident’s clinical condition, choices & identified needs, basic or routine care should include interventions to: a) Redistribute pressure (such as repositioning, protecting heels, etc) b) Minimize exposure to moisture and keep skin clean, especially of fecal contamination; c) Provide appropriate pressure redistributing, support surfaces; d) Provide non‐irritating surfaces; e) Maintain or improve nutrition and hydration status, where feasible. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 133 Short Term Goal Suggestions • • • • • • • • • • Decrease wound size by _________ cm Increase granulation tissue to_______% Decrease necrotic tissue to________% Decrease edema ___________ grade (pitting) Decrease drainage to ___________(small, moderate) Decrease odor ___________ (min, mod) Decrease erythema to_____________________ Decrease undermining or tunneling ______________ Educate patient/staff/family regarding__________ Assess efficacy of pressure redistribution devices, off‐ loading of heels, positioning, etc Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 135 134 Long Term Goals Suggestions • Wound closure in 6 wks • Functional nutrition/hydration status maintained for wound prevention and healing • Staff/family/resident safe and competent in protecting and preventing reoccurrence Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 136 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 138 Dressing Change Protocol Example Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 137 Copyright © 2014 ‐ AMT Education Division 23 Mandated Weekly or Dressing Change Monitoring • Classification/etiology Negative Pressure Wound Therapy • Anatomic location • Size • Appearance of wound bed/base • Wound Edges Electrical Stimulation • Periwound Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • Pain, tenderness, itching 139 Descriptive Some one else should be able to visualize the wound based upon your written word 141 Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com • Cowan LJ, Stechmiller J. Prevalence of wet‐to‐dry dressings in wound care. Adv Skin Wound Care. 2009;22:567‐73. • Ayello EA. The TIME principles of wound bed preparation. Adv Skin Wound Care. 2009;22(suppl1):3‐5. • Ovington L. Hanging wet‐to‐dry dressings out to dry. Home Healthcare Nurse. 2001;19(8):477‐844 • Okan D, Woo K, Ayello EA, Sibbald RG. The role of moisture balance in wound healing. Adv Skin Wound Care. 2007;20:39‐53;quiz 54‐4. • European Wound Management Association (EWMA). Position Document: Wound Bed Preparation in Practice. London: MEP Ltd, 2004. www.ewma.org • Sibbald RG, Woo K, Ayello E, Wound Bed Preparation: DIM before DIME. Wound Healing Southern Africa 2008 Volume 1 No 1:29‐34. • Carville K. Which dressing should I use? It all depends on the ‘TIMEING’. Aust Fam Physician 2006;35:486‐9. Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 142 References References • CMS: State Operations Manual, Appendix PP ‐ Guidance to Surveyors for Long Term Care Facilities, (Rev. 55, 12‐02‐09) Section ‐ 483.25 (c). • National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009 • Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 2003;11 Suppl 1:S1‐S28. • Schultz GS, Barillo DJ, Mozingo DW, Chin GA; Wound Bed Advisory Board Members. Wound bed preparation and a brief history of TIME. Int Wound J 2004;1(1):19‐32. • Mulder M, The selection of wound care products for wound bed Copyright © 2014 Gordian Medical, Inc. preparation. Wound Healing Southern Africa 2009 Volume 2 No 2. dba American Medical Technologies. www.amtwoundcare.com 140 References Wound documentation should be: Objective • Drainage/Odor Pulsatile Lavage w/ Suction Low‐frequency Ultrasound 143 • Fleck CA; Why Wet to Dry”? Journal of the American College of Certified Wound Specialists (2009) 1, 109–113. • Moffatt, CJ et at. “Understanding Wound Pain and Trauma: An International Perspective,” EWMA Position Document: Pain at Wound Dressing Changes 2‐7, 2002 • Colwell JC, Foreman MD, Trotter JP. A comparison of the efficacy and cost effectiveness of two methods of managing pressure ulcers. Decubitus 1993;6(4):28‐36. • Xakellis GC, Chrischilles EA. Hydrocolloid versus saline gauze dressings in treating pressure ulcers: a cost effectiveness analysis. Arch Phys Med Rehabil 1992;73:463‐9. • Bolton LL, van Rijswijk L, Shaffer FA. Quality wound care equals cost‐ effective wound care: a clinical model. Adv Wound Care 1997;10(4):33‐8.Colwell JC, Foreman MD, Trotter JP: A comparison of the efficacy and cost effectiveness of two methods of managing Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. 144 pressure ulcers. Decubitus. 1993;6(4):28–36. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 24 Resources References • Woo K, Ayello E, Sibbald RG, The Edge Effect: Current Therapeutic Options to Advance the Wound Edge. Advances in Skin & Wound Care. 2007 Volume 20 No 2.. • Dowsett C. The role of the nurse in wound bed preparation. Nurs Stand 2002;16(44):69‐72, 74, 76. • Gokoo G, A primer on wound bed preparation. Journal of the American College of Certified Wound Specialists 2009 1, 35‐39. • Helberg D, Mertens E, Halfens RJ, Dassen T. Treatment of pressure ulcers: results of a study comparing evidence and practice. Ostomy Wound Manage 2006;52(8):60‐72 • Armstrong MH, Price P. Wet‐to‐dry gauze dressings: fact and fiction. Published 3/03/2004. www.medscape.com/viewarticle/470257 • http://www.worldwidewounds.com/2002/april/Vowden/Wound‐ Bed‐Preparation.html Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com 145 • (UHMS) Undersea & Hyperbaric Medical Society www.uhms.org • Wound Care Institute www.woundcare.org • (WMAOI) Wound Management Association of Ireland http://www.wmaoi.ie/ • (WOCN) Wound Ostomy and Continence Nurses Society www.wocn.org • Wound Healing Foundation www.woundhealfoundation.net • (WUWHS) World Union of Wound Healing Societies www.wuwhs.org Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com (AMDA) American Medical Directors Association www.amda.com (APIC) Association for Practitioners in Infection Control www.apic.org (APMA) American Podiatric Medical Association www.apma.org (APTA) American Physical Therapy Association www.apta.org (APWCA) American Professional Wound Care Association www.apwca.org (CAWC) Canadian Association of Wound Care Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. 146 www.cawc.net www.amtwoundcare.com Resources • (EPUAP) European Pressure Ulcer Advisory Panel www.epuap.org • (ETRS) European Tissue Repair Society www.etrs.org • (EWMA) European Wound Management Association www.ewma.org • International Wound Infection Institute http://www.woundinfection‐ institute.com • (NLN) National Lymphedema Network www.lymphnet.org • (NPUAP) National Pressure Ulcer Advisory Panel www.npuap.org • Wound Care Guidelines: • – http://www.guideline.gov • (AAWC) Association for the • Advancement of Wound Care www.aawconline.org • (AAWM) American Academy of Wound • Management www.aawm.org • (ABA) American Burn Association • www.ameriburn.org • (ACFAS) American College of Foot and Ankle Surgeons • www.acfas.org • (ADA) American Diabetes Association www.diabetes.org • 147 [email protected] • Wound Certification Boards • ABWMcertified.org American Board of Wound CWS, CWCA, CWS‐P • Wcei.net –Wound Care Education Institute – WCC • WOCNCB.org Copyright © 2014 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com Copyright © 2014 ‐ AMT Education Division 148 25