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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
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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
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Pressure Ulcer Resources Recommended to be Used by Surveyors for LTC
 NPUAP
 AMDA
 WOCN
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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
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MDS 3.0
M‐Section
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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
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• 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
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Modify Interventions
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Risk Assessment Key for Prevention
Identify Individuals @ Risk
Identify & Eval Risk Factors
PrU
Prevention & Healing
Implement interventions stabilize, reduce / remove risk factors
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Critical Steps
Monitor impact of interventions
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Prevention of Other Wounds
PrU Risk Assessment Tool
Early detection: At Risk
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Identify & Eval Changes in Condition
Identify & Eval factors removed or modified
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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)
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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
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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
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(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
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Sensory
Perception
Body Temperature
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Number 1 Reason for Pressure Ulcers
Comorbid conditions
Nutrition Issues
Perfusion & Oxygenation
Nutritional Indicators
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•Decreased Mobility in bed and chair
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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
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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
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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
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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)
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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”
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• 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
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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)
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• 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
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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
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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
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Underscoring Risk Severity on Braden Scale Scores
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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.
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• 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
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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
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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
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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
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• Risk assessment • Document and address each risk in the resident’s plan of care
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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
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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
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– Adds pressure to compromised tissue
– May impede healing
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General Reposition Recommendations for All Individuals
HIGH RISK AREAS
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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
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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
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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
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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
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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
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Heels Con’t
• Who is teaching this to the CNA?
• How are you monitoring
repositioning in your facility?
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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
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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
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HOW SUPPORT SURFACES WORK
PRESSURE REDISTRIBUTION
• The ability of support surface to distribute load over contact areas of body
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• Immersion and envelopment reduce tissue stress
• Increasing the contact area between the support surface and individual’s body
• Allowing for pressure redistribution
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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
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• Examples of these surfaces or devices include:
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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
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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
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Let’s take a BREAK!!!
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Moisture Associated Skin Damage
Urinary + Fecal Incontinence
Other Skin Issues that Confuse Pressure Ulcer Identification, Reporting and Treatment
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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
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Medical Device‐Related Pressure Ulcers
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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.
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Diabetic Neuropathic Foot Ulcers
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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
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• 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
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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
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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
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Pressure Ulcers
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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).”
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• 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
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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
•
•
•
•
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Stage 2 PrU
MASD
Early venous insufficiency
Skin tears
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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




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– 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
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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).
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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.
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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.
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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.
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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.
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• 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)
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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
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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.
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Unstageable Heels
• Three types to differentiate
• Number of these unstageable pressure ulcers present upon admission/ reentry
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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
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M0300E Unstageable
Non‐Removable Dressing
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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
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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
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•
(From Farid K. Applying observations from forensic science to understanding the development of pressure ulcers. Ostomy Wound Management 2007;53(4):26‐44.)
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M1200 Skin and Ulcer Treatments1
Wound Care Interventions
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General Principles Of Wound Care
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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
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–
–
–
–
64 layers
Airborne release
Will NOT prevent bacterial contamination
3x Higher infection rate
• Frequency of change
– Fibers
• Pain 95
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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
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
Negative Pressure Hyperbaric Oxygen
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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
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• Does your facility have a functional wound assessment form or process (EMR)?
 Wound Assessment
Documentation
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Tight Blood Glucose Control
PDGF
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Dressings
Inflammation
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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
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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
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Location
Edges
• Factors that impede healing status such as co‐morbid conditions and medications
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Shape
Wound Bed
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Tissue Destruction
Pain
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Location
Date Wound Identified
Describe location anatomically correctly using current medical terminology
Specific Terms
Recurrence = Recidivism
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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
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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
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• 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
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Complicating Factors
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Measurement
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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
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NOTE: Do not record depth if not able to see TRUE base of wound. Use unstageable designation.
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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
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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.
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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
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Wound Bed
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Reporting Most Severe Tissue Type for Pressure Ulcers
1 Epithelial Tissue
2 Granulation Tissue 3
Slough
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4
All Granulation Tissue is NOT Created Equal
Healthy granulation tissue
Eschar
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Unhealthy, friable granulation tissue in infected wound
Hypergranulation tissue
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Document Necrotic Tissue
Describe Amounts and Locations in Wound Bed
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Pain
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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
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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)
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Describe Wound Edges / Periwound
• Location
• Duration
• Character (intensity and radiation)
• Frequency
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Treatment Plan
NPUAP.org
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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
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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
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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
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Dressing Change Protocol Example
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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
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• Pain, tenderness, itching
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Descriptive
Some one else should be able to visualize
the wound based upon your written word
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• 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.
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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.
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References
Wound documentation should be:
Objective
• Drainage/Odor
Pulsatile Lavage w/ Suction
Low‐frequency Ultrasound
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• 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
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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
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• (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
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(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
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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
•
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[email protected]
• Wound Certification Boards
• ABWMcertified.org American Board of Wound CWS, CWCA, CWS‐P
• Wcei.net –Wound Care Education Institute – WCC
• WOCNCB.org
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25