Joyce Black, PhD, RN 1

 Expresses ideas and facts clearly ◦ Legible ◦ Spelled correctly  Provides a record for later reference  Provides evidence of care provided 2

 Date of occurrence  Events and diseases preceding ulcer development ◦ Often assume wound is from one etiology when the true story is not known, or not carried forward  Past care rendered and outcomes (trajectory)  Current size, stage, other variables  Expected outcomes from patient’s perspective 3

 Decubitus ulcer on buttocks 4

 67 year old female who developed a sacral pressure ulcer following surgery 7 days ago  Ulcer found 2 days after surgery, it was a deep tissue injury  Placed her on low air loss bed for past 5 days and limited supine position  Has a Foley in place, oral nutrition is OK  Currently ulcer is 5 x 6 x ?, it is unstageable: fully eschar covered  Just started debridement today, had been treating it with foam dressings and skin barrier before 5

 Standard data set components inconsistent from site to site  Standard transfer form inadequate  In the interim, ask ◦ Stage, size, other attributes ◦ Date of onset, events leading to ulcer ◦ Initial care and outcome ◦ Current care and plan for future ◦ Patient and family aware 6

 Current problems ◦ Ulcers “not discovered” until stage II or beyond ◦ Staging errors ◦ Wounds that are not pressure ulcers are staged ◦ Frequency of assessment not consistent ◦ Analysis of findings not apparent  Deterioration of ulcer not addressed 7

 Ulcers not discovered until stage II or beyond  Plan of correction ◦ Teach aides to report any skin issues that are not normal  Over-reporting should be appreciated ◦ Teach aides to examine high risk areas  Heels by looking at the heel  Sacrum by separating buttocks folds ◦ Expect full skin assessment by licensed nurses  Provide a documentation system to capture the assessment and the findings  “No new skin problems” always invites concern when ulcers are known to be present 8

Teach staging with photos Validate it in real patients Monitor accuracy Once full thickness, the ulcer is “a healing stage III/IV” 9

 Stage II pressure ulcers are fairly rare ◦ Skin lesions incorrectly classified as stage II’s often include  Incontinence associated dermatitis  Skin tears  Intertriginous dermatitis  Dehisced incisions  Important to clarify in training ◦ Pressure ulcers in areas subject to pressure ◦ Wet and dry skin more prone to ulcerate ◦ Pressure ulcers should heal if etiology corrected an healing supported  Other skin lesions heal on different trajectory ◦ Pressure ulcers are a quality issue, other conditions are not always monitored in same manner 10

 Weekly assessment of skin in low and moderate risk residents OK in most cases ◦ As long as risk assessment is accurate  Daily assessment of skin in high risk residents needed ◦ Examine skin as resident is turned or cleaned ◦ Do not position back on the red area  Assessment of ulcer ◦ With each dressing change  If healing, note wound is unchanged or stable  If no change for 2 weeks, reevaluate 11

 Ulcers should heal ◦ That is, size decreases, necrotic tissue is less, slough decreases or is absent, granulation tissue appears and is pink  When ulcer is not healing, ◦ Do not continue present treatments (they aren’t working)  Document review of offloading (turning, surface), nutrition (diet and intake, weight change), topical treatments (dressing type, change frequency, etc)  Document plan to change, notification of family, preference of resident for treatment, contact with MD or WOCN 12

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