Joyce Black, PhD, RN 1. Expresses ideas and facts clearly ◦ Legible ◦ Spelled correctly Provides a record for later reference Provides evidence.

Joyce Black, PhD, RN

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Expresses ideas and facts clearly◦ Legible◦ Spelled correctly

Provides a record for later reference

Provides evidence of care provided

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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

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Decubitus ulcer on buttocks

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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

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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

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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

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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

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Teach staging with photosValidate it in real patientsMonitor accuracyOnce full thickness, the ulcer is “a healing stage III/IV”

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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

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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

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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

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