Pressure Ulcer Prevention and Treatment Checklist

Pressure Ulcer Prevention and Treatment Checklist And Toolkit To use the checklist and toolkit, click on any link for additional information. Then, click the back arrow at the top of your screen to return to the previous location. DATE COMPLETED INITIALS NO OR NOT KNOWN General Concepts The F314 tag classifies pressure ulcers as avoidable/unavoidable. Determination is based on the inclusion of the following processes: 1) Assessment of the resident’s clinical condition and risk factors 2) Interventions to address the resident’s needs consistently 3) Monitor/evaluate effects of the interventions 4) Revise interventions as appropriate Care practices for prevention, management and treatment of pressure ulcers should be based on recognized clinical standards of practice (i.e. www.ahrq.gov, www.npuap.org, www.amda.com, www.medqic.org, www.wocn.org, www.healthinaging.org The resident’s preferences/choices noted and included in the plan of care Presence of an Advance Directive and, if so, considerations that affect pressure ulcer prevention and treatment Severity Level of Tag Other Considerations: Physician Supervision  The physician assessed and developed a treatment regimen to prevent/heal pressure ulcer  Responded appropriately to the notice of changes in condition  The physician is notified of the resident’s condition, changes in the wound bed, any significant changes in the resident’s condition, or failure of the treatment plan to prevent or heal pressure ulcers Sufficient Staff  Ensure qualified staff in sufficient numbers to provide necessary care and services. Medical Director  Medical director assists in the development and implementation of policies and procedures.  If requested by the facility, interacts with the physician supervising the care of the resident to intervene on the resident’s behalf. This material was prepared by Louisiana Health Care Review, Inc. (LHCR), the Medicare Quality Improvement Organization for Louisiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. LA7SOW1A05-P425 DATE COMPLETED INITIALS NO OR NOT KNOWN Assessment I. Risk Assessment Risk assessment to identify the residents at risk of pressure ulcer formation, the level of risk, and the specific factors placing them at risk Assessment includes the following:  Identifies the individual at risk of developing a pressure ulcer  The level and nature of the risk(s)  Each risk factor and the extent to which the factor can be stabilized, reduced or removed in care process. Include a review of the following:  Pressure points  Under-nutrition  Hydration deficits  Moisture and its impact on the skin  Factors that place a resident at risk for delayed healing  Any additional risk factors. See examples  Determine interventions to address risk factors  A validated tool, such as the Braden Scale, may be used.  See sample form. Frequency of assessment  At admission  Weekly for the first four weeks after admission for atrisk residents  Quarterly  Change in condition Risk assessments should be timely and appropriate II. Skin Assessment Assessment should include:  Skin integrity  Tissue tolerance  Pressure points  Pre-existing signs  Any other pertinent findings On a daily basis, staff should be alert to potential changes in the skin condition, and evaluating and documenting the identified changes Skin condition should be evaluated at least weekly, including skin color, moisture, temperature, integrity, and turgor Skin assessments timely and appropriate III. Assessment of Pressure Ulcer General Concepts:  Identify each existing pressure ulcer and factors that contributed to its development.  Differentiate the pressure ulcer from other types of wounds/ulcers DATE COMPLETED If ulcer determined to be “other type of wound” the clinician(MD, NP, PA, certified wound care specialist, etc.) needs to document the clinical basis of the wound  Determine whether the pressure ulcer is avoidable or unavoidable. Avoidable pressure ulcers demonstrate opportunities to improve the system of care. Initial Assessment of Pressure Ulcer includes:  Location/etiology  Stage  Size (length, width, depth)  Wound bed color and tissue type  Wound edges and surrounding tissue  Exudate/drainage  Undermining, tunneling, sinus tracts  Progress toward healing; potential complications  Infecton, if present  Pain  Any other pertinent findings  Dressings and treatments Daily assessment of the pressure ulcer includes:  If no dressing is present, evaluation of the ulcer  If dressing present:  Status of dressing: intact/non-intact , presence or absence of drainage or leakage  Area surrounding the ulcer that can be observed without dressing removal  Pain  Presence of possible complications 2. Weekly assessment, or more often if changes in wound characteristics occur:  INITIALS NO OR NOT KNOWN   See Initial assessment of pressure ulcer See photographs. Interventions / Care Planning General Concepts:  Interdisciplinary team input to care plan. Sample form  Care plan meetings conducted regularly or if change in condition  Resident and family included in care plan meeting. Document invitation and attendance. Sample form 1, Sample form 2.  Assessment and appropriate care delivered from day of admission for resident at risk or with a pressure ulcer.  Interventions address the resident’s risk factors.  Prevention and management interventions have measurable goals and timetables.  Document clinical reasons why some interventions may not be appropriate.  Care plan individualized in accordance with the resident’s wishes (See resident preferences)  If the resident refuses care, complete the following: DATE COMPLETED Evaulate the basis for the refusal Risks/benefits discussed with resident Identify potential alternatives Institute potential alternatives Evaluate potential alternatives  Document what was tried, how often, the outcomes, notification to the MD and family of refusals  See resident preferences      INITIALS NO OR NOT KNOWN Positioning  Note the skin integrity after the pressure has been reduced/redistributed  Repositioning plan (i.e. frequency) should be based on the resident’s condition and tissue tolerance  Avoid placing the resident on an existing ulcer  Consider the risk of friction/shearing if lifting devices are used for repositioning  If severe flexion contractures are present, identify and address pressure points 1. For residents who can change position independently, provide:  Explanations of why and how to change position regularly  Reminders to change position frequently  Monitoring the frequency of repositioning  Supportive devices as needed 2. For the resident who is dependent on staff for repositioning, the care plan should address: Reclining position  Avoidance of positioning on the greater trochanter for more than momentary placement  The head of bed being elevated no higher than 30 degrees, if resident’s medical condition allows  For the dependent resident who requires elevation of the head of the bed, or sits in a recliner with elevation of 30 degrees or more, hourly position changes may be needed  Document clinical valid reasons why some interventions are not appropriate (i.e. HOB up r/t respiratory condition) Chair positioning  At least hourly repositioning  Educating the resident to shift his/her weight every 15 minutes, if feasible  Postural alignment  Weight/ pressure distribution  Sitting balance and stability DATE COMPLETED INITIALS NO OR NOT KNOWN Support surfaces  Choose a support surface/device that matches therapeutic benefit with the resident’s specific situation.  Support surface/device should be:  In place  In proper working condition  Used according to manufacturers guidelines  Consider the need to redistribute/eliminate pressure on elbows and heels Nutrition/Hydration     Nutrition and hydration assessment Monitor weight stability. Continued weight loss or failure of a pressure ulcer to heal warrants further assessment. Interdisciplinary team develops nutritional goals. Plan of care addresses identified deficits. Urinary and/or fecal incontinence     Interventions to address moisture and its impact Pain Assess pain and intervene appropriately. Consider preemptive measures for pain related to dressing changes/treatments. Monitor interventions for effectiveness. Dressings and Treatments  See assessment of pressure ulcers.     Treatments are in accordance with facility’s policies and procedures and based on current clinical standards of practice. Pain management needs addressed as appropriate. Treatments in line with advanced directives and the resident’s wishes. Policies and procedures developed with the medical director’s review and approval. Infection Provided appropriate interventions, care and treatment to minimize infections and promote healing DATE INITIALS NO OR COMPLETED NOT KNOWN Monitor and Evaluate Effectiveness of Care Plan       Impact of the interventions should be monitored. Care plan interventions modified appropriately. If new pressure ulcer develops, care plan must be reevaluated and modified accordingly. Changes in conditions are recognized, evaluated, reported to the practitioner and addressed. Care plan evaluated at specified intervals, specific triggers, and updated as needed. Systems in place to assure protocols for daily monitoring, periodic documentation of measurements, terminology, frequency of assessment and documentation implemented consistently. Q & A Committee reviews the following:  Existing pressure ulcer strategies  Incidence and prevalence of pressure ulcers  Ensure policies/procedures consistent with current standards of practice  Evaluation of Wound Healing  According to F314 tag, wound healing should be assessed within 2-4 weeks of treatment. (Best practice is within 2 weeks.) PUSH tool may be used.  Failure to show progress toward healing within 2-4 weeks or worsening of an existing pressure ulcer, requires reassessment of the resident’s overall condition and care plan.  If facility maintains the current care plan in the absence of healing, document the rationale for continuing the treatment. Pressure Ulcer Prevention and Treatment Toolkit This toolkit is intended to assist the resident’s care team in assessing, developing the plan of care, implementation, monitoring the effectiveness, and revising the plan of care, as indicated, to meet the individual resident’s needs. By consistently applying the checklist, the team is more likely to reduce the development of new pressure ulcers and promote healing of existing ulcers. A quality assessment and assurance committee may help evaluate existing strategies, monitor the incidence and prevalence of pressure ulcers within the facility, and make sure that policies and procedures are consistent with current standards of practice. F314 Pressure Ulcer Tag notes the following: Based on the Comprehensive Assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable and that the facility provides care and services to: promote the prevention of pressure ulcer development; promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and prevent development of additional pressure ulcers. Avoidable Pressure Ulcer: A pressure ulcer developed related to the facility failing to complete one of the following: 1. Evaluate the resident’s clinical condition and pressure ulcer risk factors. 2. Define and implement interventions that are consistent with resident needs, resident goals and recognized standards of practice. 3. Monitor and evaluate the impact of the interventions. 4. Revise the interventions as appropriate. Unavoidable Pressure Ulcer: The resident developed a pressure ulcer even though the facility had completed the above processes. Web References Follow practices for prevention, management and treatment of pressure ulcers from a recognized clinical resource i.e. www.ahrq.gov, www.npuap.org, www.amda.com , www.medqic.org , www.wocn.org , www.healthinaging.org . Resident’s Preferences/Choices In order for a resident to exercise his or her right appropriately to make informed choices about care and treatment or to refuse treatment, the facility and the resident (or the resident’s legal representative) must discuss the resident’s condition, treatment options, expected outcomes, and consequences of refusing treatment. The facility is expected to address the resident’s concerns and offer relevant alternatives if the resident has refused specific treatments. Advance Directive If an advance directive exists, the care plan should be individualized in accordance with the resident’s expressed wishes. The existence of an advance directive does not absolve the facility from giving supportive and other pertinent care that is not prohibited by the Advance Directive. To meet regulatory requirements, the facility should implement appropriate efforts to stabilize the resident’s condition to prevent or treat pressure ulcers (or indicate why the condition cannot or should not be stabilized) in accordance with the resident’s wishes. Severity Level of F314 Tag Severity Level 1: No longer applies for this tag. Severity Level 2: No Actual Harm with Potential for More than Minimal Harm (not IJ). Examples:  Development of a single avoidable Stage II pressure ulcer that is receiving appropriate treatment.  Development of one avoidable Stage 1.  Failure to implement an element of the care plan for a resident with a pressure ulcer without a decline or failure to heal.  Failure to recognize or address the potential for developing a pressure ulcer. Severity Level 3: Actual Harm that is not Immediate Jeopardy Examples:  Development of an avoidable Stage III  Recurrent or multiple avoidable Stage IIs  Failure to implement the comprehensive care plan for a resident who has a pressure ulcer Severity Level 4: Immediate Jeopardy Examples:  Development of an avoidable Stage IV  Admitted with a Stage IV that has no signs of healing or shows signs of deterioration  Stage III or IV with associated soft tissue or systemic infection  Extensive failure in multiple care areas Risk Assessment – The purpose of a risk assessment is to identify residents at risk of developing pressure ulcers or to address risk factors in residents with existing skin breakdown so that appropriate interventions can be promptly initiated. A comprehensive assessment should address risk factors that have been identified as having an impact on the development, treatment and healing of pressure ulcers Although, federal regulations do not require that a specific tool be used, existing guidelines recommend the use of a validated tool. Examples of a validated tool include the Braden or Norton scales. The Borun Center (http://borun.medsch.ucla.edu) recommends the Braden scale because it has been used more extensively in nursing homes and in nursing home research. These tools enable determination of a risk score which helps to objectively identify the level of risk, the risk factors, and changes in risk. Regardless of the total risk score, individualized interventions to address risk factors still need to be implemented. The guidelines also establish the frequency of risk assessment, with emphasis on early identification and intervention because of the increased risk that is present in the days and weeks following admission. Examples of risk factors include the following:       Impaired or decreased mobility Decreased functional ability Co-morbid conditions such as ESRD, thyroid disease, diabetes mellitus, severe COPD, severe PVD, sepsis, end-stage disease Medications, such as steroids, that may affect healing Impaired diffuse or localized blood flow: i.e. generalized atherosclerosis or lower extremity arterial insufficiency Resident refusal of some aspects of care and treatment           Cognitive impairment Exposure of skin to urinary and/or fecal incontinence Under nutrition, malnutrition Hydration deficits History of a healed pressure ulcer and its stage (if known), since stage 3 or 4 ulcers are more likely to have recurrent breakdown Impaired sensation, diabetic neuropathy, paralysis, degenerative neurological disease/injury Edema Medical devices, such as indwelling catheters, casts An acute illness, exacerbation of a chronic condition, or another change in condition Other Skin assessment Regularly conduct thorough skin assessments on each resident who is at risk of developing pressure ulcers. Such skin assessments allow early detection of a developing or existing skin breakdown, and verify the integrity of the skin. After the reduction or redistribution of pressure, determine tissue tolerance: the ability of the skin and underlying tissue to endure the effects of pressure. This may assist in determining the frequency of repositioning. For example, guidelines recommend dependent, reclining residents to be repositioned every two hours. However, for some high-risk residents, this assessment may show that repositioning at a 2-hour interval is inadequate, and more frequent repositioning is warranted. Pressure points. The most common include: sacrum, heel, greater trochanter, ischial tuberosity, fibular head, scapula, ankle, and elbow. Diagram of pressure points on next page. COMMON SITES OF PRESSURE ULCERS A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. They are usually located over bony prominences Pressure points of bony prominences Occiput Acromion process Thoracic vertebrae Scapula Lumbar vertebrae Olecranon Sacrum Ischial tuberosity Lateral knee Medial malleolus (inner ankle) Lateral malleolus (outer ankle) Metatarsals (toes) Calcaneus (heel)  Assess for pre-existing signs of tissue damage: purple or a very dark area that is surrounded by redness, edema or indurations suggesting that deep tissue damage has already occurred and additional deep tissue loss may occur. It is important that the individual conducting the assessment be knowledgeable and skilled in detecting erythema in darkly pigmented individuals. The presence of such damage could herald the subsequent appearance of an unavoidable Stage III or IV pressure. Differentiate Pressure Ulcers from “Other Types of Wounds” When a wound develops, it should be noted whether it is a pressure ulcer or an “other type of wound.” If the wound is not a pressure ulcer, the clinician (physician, advance practice nurse, PA, and certified wound care specialist, etc.) should document the clinical basis for determining an ulcer is not pressure-related. Complete documentation should address the type of skin injury/ulcer, location, shape, ulcer edges, wound bed, and condition of surrounding tissues. The table below provides a summary of characteristics for the most common wounds that must be distinguished from pressure ulcers. Of the three, venous insufficiency ulcers are the most common. Arterial Underlying condition Non-pressure related disruption or blockage of arterial blood flow Diabetic Neuropathic DM with peripheral neuropathy Venous Insufficiency Currently literature implicates venous HTN. Predisposing factors include: valve incompetence in perforating veins, history of deep vein thrombophlebitis and thrombosis, previous history of ulcer, obesity, advanced age Irregular wound margins Moist, granulating, superficial Minimal to copious Pretibial area of lower leg or above the medial ankle Firm edema, dilated superficial veins, dry, thin, scaly skin, periwound and leg hyperpigmentation, evidence of healed ulcers, possible dermatitis or cellulitis Usually minimal to moderate pain, pain could increase when foot in dependent position Ulcer edges Wound bed Exudate Location Other Even wound margins Deep, pale wound bed Minimal to none Usually distal portion of the lower extremity, ankle, foot Diminished or absent pedal pulse, decreased temperature, pallor upon elevation and dependent rubor, delayed capillary fill time, hair loss on top of foot and toes, toenail thickening Increased pain when elevated, decreased pain in dependent position, intermittent claudication Pain Even wound margins Granular tissue present unless coexisting PVD Low to moderate drainage On plantar aspect of foot, over metatarsal heads; under heel Diminished or absent sensation in foot, foot deformities, palpable pulses, warm foot, subcutaneous fat atrophy, cellulitis or underlying osteomyelitis, arterial assessment findings if resident also has PVD Painless Staging Staging is one method of summarizing certain characteristics of pressure ulcers. Stage I: An observable, pressure-related alteration of intact skin, whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain or itching) and/or a defined area of persistent red, blue, or purple hues. Stage II: Partial thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage III: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers. Note: If eschar and necrotic tissue are covering and preventing adequate staging of a pressure ulcer, the RAI User’s Manual Version 2 instructs the assessor to code the pressure ulcer as a Stage IV. Present coding system requires completion of RAI to record healing stages. For MDS coding purposes, staff is instructed to identify the stages of pressure ulcer(s) by describing depth in reverse orders from deepest to lesser stages to describe the healing or improvement of a pressure ulcer. This has been referred to as “reverse staging” or “back staging” Infection  Classic signs of infection: purulent exudates, peri-wound warmth, swelling, induration or erythema, increasing pain or tenderness around the site or delayed wound healing  Classic signs may not always be evident, such as an immunocompromised resident. Some infections may present primarily with pain or delayed healing without other clinical signs of infection.  To classify a wound as infected the following criteria should be met: the wound has signs and symptoms of infection and/or a wound culture (obtained in accord with accepted standards, such as sterile tissue aspirate, a “quantitative surface swab” using the Levine technique; or a semi-quantitative swab that contains 100,000 or greater micro-organisms per gram of tissue.)  Note: a superficial swab is not a reliable method to identify infection.  Current literature reports that although all Stage II, III, IV are colonized with bacteria, they may not necessarily be at the point of clinical infection.  Other findings, such as an elevated white blood cell count, bacteremia, sepsis, or fever may signal an infection related to a pressure ulcer area or a co-existing infection from a different source. Infection control practices should reflect current standards of care. Photographs Photographs may be used for documentation if there is a protocol consistent with accepted standards. Buckley, et al, recommends the protocol should consider the following:        Informed consent HIPAA compliant Within photo, include: resident identification(i.e. number), date, body part (ulcer location), measuring device to determine cm Avoid resident’s identifying characteristics in photo i.e. face, tattoo Parameters for frequency For serial images: consistent positioning, distance and angle from the wound Take at least 3 images: a. close-up using zoom to document detail b. midway shot of the wound to capture at least a 4-6” border around the periwound c. distant shot (e.g. showing entire extremity) Type of equipment used Means to assure images are accurate and not modified Appropriate infection control procedures Other Buckley,K., et al. Get the picture! Developing a wound photography competency for home care nurses. J WOCN, 2005, 32(3),171-177.     Support Surfaces To choose an appropriate surface/device, match the device’s potential therapeutic benefit with the resident’s specific situation. Consider the following:  Individual’s risk  Positioning of the resident  Weight of the resident  Contractures  If healing expectations are being met  If pressure may be contributing delayed healing  Individual’s response to the product Static- Static surfaces are indicated when a resident is at risk for pressure ulcer development or delayed healing. For the residents with a pressure ulcer, a static support surface can be used if the resident can assume a variety of positions without bearing weight on a pressure ulcer and without “bottoming out.” Examples of static surfaces include solid foam, convoluted foam, or gel mattress. Dynamic - A dynamic surface may be indicated when:      the resident cannot assume a variety of positions without bearing weight on a pressure ulcer, or the resident fully compresses a static support surface, or the pressure ulcer is not healing as expected. Example: alternating air-filled overlay Low-air loss bed/ Air Fluidized bed If a resident has large Stage III or Stage IV pressure ulcers on multiple turning surfaces, a lowair-loss bed or an air fluidized bed may be indicated. Nutrition Before instituting a nutritional care plan, summarize resident-specific evidence including severity of nutritional compromise, rate of weight loss or appetite decline, probable causes, individual’s prognosis, projected clinical course, and resident’s wishes and goal. Continuing weight loss requires additional caloric intake or correction of conditions creating hypermetabolic state. Failure of a PU to heal despite improved caloric and nutritional intake may indicate multi-system failure, end-stage, or end of life condition warranting additional assessment of the resident’s overall condition. An Interdisciplinary team should develop nutritional goals. Unless contraindicated, the goal for a nutritionally compromised resident, who has a PU or is at risk of developing one, should include protein intake of approximately 1.2-1.5 gm/kg body weight daily (higher end of the range if larger, more extensive or multiple wounds.) Hydration Address hydration in residents at risk for hydration deficit or imbalance, including all residents with pressure ulcers or at risk for pressure ulcers. Moisture Plan to address potential for skin irritation and maceration due to skin exposure to feces, urine, sweat, or other source of moisture. Moisture can make the skin more susceptible to damage from friction or shearing. If incontinence with erythema is present, it must be determined whether the redness represents dermatitis related to the incontinence or Stage 1 pressure ulcer. This determination is based on clinical evidence and review of the presenting risk factors. Stage 1 pressure ulcer: localized area of erythema or skin discoloration with pressure as contributing cause. Perineal dermatitis: diffuse area of erythema or discoloration where the urine/stool has come in contact with the skin. This is particularly prone to occur in an area under an incontinence brief or resting on an underpad. It is typically associated with intense erythema, scaling, itching, papules, weeping and eruptions. The guidance for surveyors for the F315 tag addresses the appropriate care for a resident with urinary continence. According to the several pressure ulcer guidelines, interventions to manage urinary and/or fecal incontinence may include the following:  Address the cause if possible  Bowel/bladder program  Use of a commercial moisture barrier  Use of absorbent pads or disposable briefs that wick moisture away from the skin PUSH Tool The National Pressure Ulcer Advisory Panel’s Pressure Ulcer Scale for Healing (PUSH) tool documents pressure ulcer healing consistent with the healing process, and describes a healing pressure ulcer in terms of three ulcer characteristics. A numeric value is assigned to each of these characteristics: length x width (cm), exudate amount, and type of tissue (closed with epithelium, new pink, shiny epithelial tissue; clean, pink or beefy red, shiny, moist granulation tissue; slough tissue; or necrotic, eschar tissue). The tool can be found at http://www.npuap.org/PDF/push3.pdf . CLINICALLY UNAVOIDABLE PRESSURE SORE GUIDELINES Clinical conditions that are the primary risk factors for developing pressure sores include, but are not limited to, resident immobility and list all that apply: ASSESSMENT DATE 1.The resident has two or more of the following diagnoses: A Severe COPD F Comatose/Semi comatose B Severe PVD G Paraplegia C Sepsis H Quadriplegia D Diabetes I Terminal Cancer E Immunosuppression J Full Body Cast (disease or drug related) 2. The resident receives two or more of the following treatment: A Steroid Therapy C Chemotherapy B Renal Dialysis D Head of Bed elevated the majority of the day due to medical necessity K L M N O Chronic Bowel Incon. Chronic Urinary Incon. Chronic End Stage Renal Chronic End Stage Liver Chronic End Stage Heart E Radiation Therapy 3. Laboratory values that may indicate malnutrition/dehydration or risk for poor healing: A Serum Albumin below 3.4g/dl E Hgb. Less than 12g/dl B Prealbumin below 18g/d F Serum transferrin below 180g/dl C Total protein less then 5.1g/d G BUN more than 21mg/dl D Creatinine more than 1.3mg/dl 4. Clinical signs and symptoms that may indicate malnutrition/dehydration: A Pale skin E Weight loss of 5% in one month, 7.5% in 3 months or 10% in 6 months B Poor skin turgor F Red swollen lips C Bilateral edema G Cachexia D Swollen-dry tongue with H Calf Tenderness scarlet or magenta hue I J K Reduced urine output Decreased mental status Muscle wasting 5. Interventions (examples) A Vitamin Therapy B Float Heels C I&O D High Protein Foods E Positioning Pillows Other: J K F G H I Encourage 75-100 % of meal Pressure reducing devices Supplements-Dietary Weekly Weight M N SIGNATURE/TITLE/DATE ASSESS ASSESS SIGNATURE/TITLE/DATE 1 2 RESIDENT NAME ROOM NUMBER 3 4 PHYSICIAN MEDICAL RECORD # Date: _________________________ Dear: _________________________ Please join us on _______________________________ for a Wound Care Meeting about resident __________________________________. This meeting is to inform you of the condition and treatment plan for your loved one. An opportunity to view the wounds and ask questions will be afforded to you at this time. Thank you in advance for your time and preparation. Sincerely, TREATMENT AND ASSESSMENT UPDATES FOR THE PHYSICIAN, D.O.N., AND FAMILY Resident:________________________________________Date:________________Physician:_________________ Diagnosis:_____________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Location: Stage: In House_________ Admitted with_____ Treatment Order: Interventions: Assessments: Improving Unchanged Deteriorating _____ _____ _____ Comments: PHYSICIAN’S SIGNATURE __________________________________________________ DATE ___________ FAMILY’S SIGNATURE _____________________________________________________ DATE ___________ D.O.N.’S SIGNATURE _______________________________________________________ DATE ___________ TREATMENT NURSE’S SIGNATURE __________________________________________ DATE ___________ WOUND CARE MEETING Date: _____________________________ Residents discussed: ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Staff present: ________________________ ________________________ _________________________ _________________________ Family or Responsible Party: ________________________ ________________________ _________________________ _________________________ Recommendations: _____________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Family request: _____________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Next scheduled meeting: _______________________________________________ References Bryant, Ruth. Acute and chronic wounds: nursing management. Mosby, St Louis, Missouri, 1992. Buckley,K., et al. Get the picture! Developing a wound photography competency for home care nurses. J WOCN, 2005, 32(3),171-177. CMS Manual System. Pub. 100-07 State operations Provider Certification Transmittal 4. Department of Health and Human Services Centers for Medicare and Medicaid Services. November 12, 2004. Hess, Cathy. Clinical guide to wound care (4th edition). Springhouse Corporation, PA. 2002, 1-108. Wound Ostomy and Continence Nurses Society. Guideline for prevention and management of pressure ulcers. WOCN, IL, 2003. Web Sites: Agency for Healthcare Research and Quality: www.ahrq.gov ; Pressure Ulcer Guidelines http://www.ahrq.gov/clinic/cpgonline.htm#Archive American Medical Directors Association: www.amda.com The Anna and Harry Borun Center for Gerontological Research: http://borun.medsch.ucla.edu Medicare Quality Improvement Community: www.medqic.org The National Pressure Ulcer Advisory panel: www.npuap.org http://www.npuap.org/PDF/push3.pdf Wound Ostomy and Continence Nurses Society: www.wocn.org