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A Nursing Home’s Guide to Prevention and Treatment

Gauging Pressure Ulcers:

Pressure ulcers are a significant problem across all ages and health care settings. Multiple factors put residents at risk for developing a pressure ulcer, including immobility, chronic illness, incontinence, poor nutrition, altered level of consciousness, altered sensory perception and a history of having pressure ulcers.1

Pressure ulcers come at a high cost to everyone. They result in pain, suffering, diminished quality of life and even death for some residents. For a nursing home, they represent extra staff hours and medical supplies spent caring for a preventable condition, as well as more residents hospitalized. The cost of treating a single full-thickness pressure ulcer can be as high as $70,000, with the total treatment cost for pressure ulcers in the US surpassing $11 billion per year.2

Although pressure ulcers are preventable, more than one in every 10 of Missouri nursing home residents developed a pressure ulcer in 2007. The Centers for Medicare & Medicaid Services has long focused on helping nursing homes prevent pressure ulcers, but in 2008 they extended this effort across care settings. Hospitals now have a payment incentive to partner with nursing homes on pressure ulcer prevention – a good thing since 20 percent of nursing home pressure ulcers originate outside the nursing home, generally in the acute hospital setting.

No matter where you are in your prevention efforts, now is the time to take a look at your care processes with fresh eyes. First, review what the law says about pressure ulcers. See this toolkit’s summary of the federal guidelines – Understanding CMS Interpretation of Tag F314. Then, use the included Pressure Ulcer Facility Assessment Checklists to take a critical look at your current practices. Every one of these systems is crucial to pressure ulcer prevention, so take your time completing this assessment. As you assess, call on other staff to help you answer questions completely and honestly. Once you’ve completed the assessment and identified key areas for improvement, review the clinical reference tools, reminder tools and sample forms included in this toolkit. Feel free to adapt them to meet your individual needs.

1 Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006; 296: 974-984.2 Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006;296:974-984.

Gauging Pressure Ulcers: Introduction

Pressure Ulcers: Table of Contents

I. Guidelines and Example Policies a. Understanding CMS Interpretation of F314 b. MDS Skin Condition Coding Tip Sheet

II. Facility Assessment and Protocols a. Facility Assessment Checklists b. Sample Protocol

III. Resident Assessment and Monitoring Tools a. Braden Scale b. Skin Tear Risk Assessment c. LTC Dehydration Risk Assessment d. Comprehensive Admission Skin Assessment e. Licensed Nurse Weekly Skin Assessment f. CNA Shower Assessment g. Daily Skin Monitoring Tool h. Systems Investigative Audit Tool

IV. Prevention Tools a. Pressure Ulcer Prediction, Prevention and Treatment Pathway b. Tissue Tolerance and Individualized Turning Schedule c. Managing Tissue Loads d. Support Surface Characteristics and Considerations

V. Treatment Tools a. Treatment Product Categories b. Nutritional Wound Healing Guidelines c. Selected Characteristics for Support Surfaces

VI. Communication Among Providers a. SBAR Skin Care Instructions

VII. Facility/Staff Education a. Staging Guidelines from National Pressure Ulcer Advisory Panel b. Pressure Ulcer Classification Pocket Cards (see www.primaris.org) c. CNA Knowledge and Attitude Survey

This table of contents provides an overview of the assessment and clinical reference tools for pressure ulcers contained in this document. For further information, see the following pages for tool descriptions organized by section. If you’re viewing this document on your computer, click on the tool name in the table of contents below, and you will be taken directly to the resource. To download and print tools individually, go to www.primaris.org.

I. Guidelines and Example PoliciesUnderstanding CMS Interpretation of F314: Summarizes the changes that CMS put into place with the revision of F-Tag 314. Any time you make changes, quickly review this summary to ensure that you are meeting federal guidelines.

MDS Skin Condition Coding Tip Sheet: Use this tip sheet to see, at a glance, how your coding questions might be addressed by the RAI manual.

II. Facility Assessment and ProtocolsFacility Assessment Checklists: Complete this checklist as you review your approach to pressure ulcer prevention and treatment. It will help determine your plan’s comprehensiveness, its alignment with F-Tag 314 and good clinical practice.

Sample Protocol: Use this protocol as a guideline for establishing a comprehensive Pressure Ulcer Prevention and Management Policy. Download the file as a separate Word document and modify it to suit your practices and materials.

III. Resident Assessment and Monitoring ToolsBraden Scale: The Braden Scale is a research-based risk assessment used widely in the nursing community. The format allows for four separate assessments to aid in monitoring change over time.

Skin Tear Risk Assessment: Evaluating for skin tear risk and interventions is different than evaluating for pressure ulcer risk. The skin is our first line of defense, and we must protect the skin not only from pressure ulcers but from skin tears as well. This assessment helps determine if a resident is at risk for skin tears and offers potential interventions and a chart review audit, encouraging staff follow-through.

LTC Dehydration Risk Assessment: Inadequate fluid intake can place residents at increased risk for pressure ulcers. This tool will help determine resident dehydration risk, enabling staff to take a proactive approach.

Comprehensive Admission Skin Assessment: Conducting a baseline comprehensive assessment of the skin is vital. Staff may use this form to guide them through the assessment.

Licensed Nurse Weekly Skin Assessment: All residents should have their skin assessed weekly by a licensed nurse. This form encourages continuity in this documentation.

CNA Shower Assessment: This form recognizes the important role CNAs play in pressure ulcer prevention and empowers them to do regular skin checks. It provides a formal method of communication to the licensed nurses of their review of residents’ skin, which then would be followed up by the licensed staff.

Daily Skin Monitoring Tool: This tool provides a formal approach for CNAs to report areas of concern with the resident’s skin daily. The licensed staff would then follow-up on noted areas of concern to provide a complete assessment.

Systems Investigative Audit Tool: Use this tool as a guide during a chart review to ensure all appropriate steps are being taken for pressure ulcer prevention and management.

continued on next page >

Pressure Ulcers: Tool Descriptions

IV. Prevention ToolsPressure Ulcer Prediction, Prevention and Treatment Pathway: This pathway assists staff in determining the appropriate care for the individual resident. It aids in staff critical thinking skills to ensure all areas of concern are met.

Tissue Tolerance and Individualized Turning Schedule: This form can be used to document the assessment that led to the individualized turning schedule.

Managing Tissue Loads: Use this tool to systematically choose the right mattress or wheel chair cushion, based upon a resident’s level of need.

Support Surfaces: Characteristics and Considerations: Use this in-depth reference to learn more about the different support surfaces available for pressure ulcer prevention or treatment.

V. Treatment ToolsTreatment Product Categories: Use this list outlining the major types of products to ensure your nursing center carries an appropriate range of materials for pressure ulcer treatment. Nursing staff should choose the most effective dressing type based on wound stage, characteristics and potential concerns.

Nutritional Wound Healing Guidelines: This sample procedure helps enhance pressure ulcer healing by providing recommendations for nutritional intervention whenever possible. These are guidelines only. Individual patient and resident needs must be taken into consideration before implementation.

Selected Characteristics for Support Surfaces: This quick visual reference compares the characteristics of the different types of support surfaces.

VI. Communication Among ProvidersSBAR Skin Care Instructions Form: Provides a standardized format for communication using the SBAR (Situation, Background, Assessment, Recommendations) model. This form would be used in communication from wound care nurse to unit nurse for the prevention and/or management of pressure ulcers.

VII. EducationResident and Family Education Brochure (PUP): Use this brochure to proactively inform residents and families about individual risk factors and prevention techniques associated with skin breakdown so they can be be involved in prevention.

Staging Guidelines (National Pressure Ulcer Advisory Panel): These are the most up-to-date guidelines for assessing the state and the subsequent documentation of pressure ulcers.

Pressure Ulcer Classification Pocket Cards: Two double-sided reference cards were designed to assist clinical staff in the assessment, measurement and documentation of wounds. Go to www.primaris.org to download a pdf of the cards. Primaris partner homes may order laminated copies.

CNA Knowledge and Attitude Survey: CNAs’ participation is vital for the prevention of pressure ulcers. This survey will assess what your CNAs know about pressure ulcers and discover areas in which they could benefit from further education.

Pressure Ulcers: Tool Descriptions

This document summarizes key points of CMS guideline Tag F314, which state surveyors use as guidance to help them assess nursing homes’ pressure ulcer prevention and treatment. Use this as guidance for assessing the processes in place at your home with regard to pressure ulcer prevention, assessment, intervention, monitoring and care planning.

Understanding CMS Interpretation of F314

Regulations: Pressure Ulcers

F314 42 CFR 483.25 (c) Pressure soresBased 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; andA resident having pressure sores receives necessary treatment and services to promote healing, prevent •infection and prevent new sores from developing”

F314 IntentPromote the prevention of pressure ulcer development•Promote healing of pressure ulcers that are present•Prevent development of new pressure ulcers•

Survey: Pressure Sore Investigative ProtocolObjective:

To determine if the identified pressure sore(s) is avoidable or unavoidable•To determine the adequacy of the facility’s pressure sore treatment interventions•

Risk ManagementIdentify and manage resident and facility risks•Prevention of pressure ulcers benefits everyone•Educate all staff on an ongoing basis•Provide care based on accepted standards of practice (WOCN, AHQR, NPUAP)•Document care based on accepted standards•Make Care plans realistic especially when discussed with family in care plan conferences•Watch for indicators of major system failures and initiate quality improvement activities•Document facts, not assumptions•Rising litigation•

What happens when the treatment sheet is not signed off? –What happens when one lapse in weekly assessment occurs in a period where the wound declines? –*Careful with dressings that stay on several days: What happens with weekly assess? –Carefully consider policies on wound photography: may be “double-edge” sword –

Understanding CMS Interpretation of F314: page 2

Three Key Factors for Risk Management Medical record must show standard of care for pressure ulcers was adhered to•Medical record must have documentation of resident complications, risk factors, and/or underlying disease •that made the pressure ulcer unavoidable (if it is indeed)You must provide a comprehensive and aggressive program to prevent and treat the pressure ulcer (within •the parameters of resident advance directives)

PreventionWhat systems are in place in your facility?•

How is risk communicated to staff? –Are there protocols for repositioning and pressure relief products that are understood by staff? –How are you sure this is done for new admissions or those with change in status? –Residents cannot afford to wait! –

How are moisturizers/barriers stocked?•During “off-hours,” do staff know how to access pressure-reducing devices?•Are tracking and assessment forms stocked?•How are disposable briefs and underpads stocked and used?•

Assessment

Avoidable vs. Unavoidable Pressure UlcersAvoidable• – Pressure ulcer developed and facility failed to do one or more:

Defined/implemented interventions CONSISTENT with resident needs, goals ▷Recognized standards of practice (AHCPR, AMDA, WOCN, current literature) ▷Monitor and evaluate impact of interventions ▷Revise interventions appropriately ▷

Unavoidable• – Resident developed pressure ulcer although facility:Evaluated clinical condition and risk factors ▷Defined and implemented interventions consistent with resident’s needs, goals, standards of practice ▷Monitored and evaluated impact of interventions ▷Revised approaches appropriately ▷

Frequency of Risk Assessment (Braden or Norton most common)Minimally•

upon admission ▷quarterly ▷upon Significant Change in Condition ▷

Best Practice•day 7, 14, 21, 28 (post-admission) then as above ▷during acute illness ▷


Wound AssessmentAssessment includes a full description of the wound and peri-wound•Measurements alone do not constitute an assessment•Reassess weekly at a minimum•Reassess daily if pressure ulcer is deteriorating•

Staging AssessmentDoes your facility policy address your process for staging?•Who does initial staging? How is it confirmed?•What are you staging? All open areas or only pressure ulcers?•Is there a facility tool for documenting staging?•

Risk Assessment – Facility WideEstablish written guidelines, protocols, algorithms/decision trees based on risk•Low risk does not equal no risk•Let low scores trigger your mind clinically: don’t just treat the conglomerate of score•Use appropriate interventions based on the risk assessment•

Interventions

Address Risk FactorsSkin care:• routine inspections, cleansing, moisturizing, avoid massageRepositioning:• 1 hour in chair by staff, 15 minutes in chair by resident; 2 hours in bedPressure relief• for heelsPressure reduction• devicesAddress nutrition•Address incontinence•Toileting schedule? Rehab? Positioning evaluations? Incontinence products?•

Combination of Prevention InterventionsAdequate nutrition and hydration•Repositioning schedule and positioning•Appropriate support surfaces•Care of skin•

Monitoring Wound Status

Is It Better or Worse?Objectively review wound progress: measurements, type of tissue, PUSH tool•Subjective assessments are problematic:•

“I don’t think this treatment is working. I’m calling the MD to change the treatment…” –“The pressure ulcer is deeper than last week - of course it is worse” - not necessarily true –

MO-08-11-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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. Adapted from CMS Provider Certification, Transmittal 4, November 12, 2004; HCPro Pressure Ulcer Materials, 2004; & Pressure Ulcers F-314 by Courtney Lyder, September 2004

Document available at www.primaris.org


Monitoring Treatment PlanIs there a process for monitoring treatment?•Is there a tracking tool to document response to treatment?•Does the tracking form monitor the appropriate wound variables?•Are there protocols for changing the treatment if it is ineffective?•Healing - a systemic process affected by systemic conditions - treatment is more than a dressing•When do you change the treatment?•What determines frequency of dsg change•How do you handle “non-traditional” recommendations or a product being used in a manner different than •its intended use?

Care Planning Do care plans identify risk factors?•Are you treating the risk factors?•Is the resident and family aware of and in agreement with goals?•Goal must be a clear statement of intended progress and how it will be measured•Be REALISTIC!!!!•Determine what the goal is:•

Maintenance –Improvement/Healing –Comfort –Many goals beyond healing… –

Resolution of periwound erythema in 2 weeks ▷25% reduction in amount of necrotic tissue by 1 week ▷Decrease in intensity of pain during dressing changes from 6 to 3 (as reported by resident) by 1 week ▷1 cm reduction in wound dimensions by 2 weeks ▷

MDS Skin Condition Coding Tip Sheet

Document available at www.primaris.orgMO-08-47-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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.

DefinitionAccording the RAI Manual “A skin ulcer can be defined as a local loss of epidermis and variable levels of dermis and subcutaneous tissue, or in the case of Stage 1 pressure ulcers, persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved.” (RAI Manual, pgs. 3-159)

CodingM1 - recording of all skin ulcers if caused by pressure or circulatory problems.M1 - recording of all skin ulcers if caused by pressure or 1. circulatory problems.M2 - differentiates between pressure or venous stasis 2. ulcers only; record highest level of each.M3 - history of resolved/cured ulcers. Definition same as for M1.3.

M4 - records skin problems or lesions not caused by 4. pressure or circulatory problems.M5 - records any specific or generic skin treatments.5. M6 - records specific foot problems and care.6.

ProcessReview the record and check with appropriate nursing 1. staff for the presence of any skin problems.Examine the resident for condition (stage, number) of 2. any skin problems. Coding will be based on what is seen (i.e. visible tissue) during the look back period. NPUAP standards cannot be used for coding on the MDS. MDS defined staging is used for M1 and M2 only.Determine the cause of the skin ulcer. If it is caused from 3. pressure or circulation (venous or arterial) then it is coded in M1. All remaining skin ulcers then are documented in

ClarificationNecrotic eschar prohibits accurate staging. Code the skin 1. ulcer with eschar as Stage 4 until debrided. Good clinical practice dictates that the ulcer be re-2. examined and re-staged after debridement.If a skin ulcer is repaired with a flap graft, it is coded as a 3. surgical wound and not as a skin ulcer.

Skin ulcers should be coded in either M1, with further 4. clarification in M2, or in M4. Pressure or stasis ulcers coded in M2 should not be coded in M4.If skin ulcers are captured in M1 or M4, good clinical 5. practice would also have something documented in M5 under treatment.For MDs coding, ankle problems are not considered foot 6. problems.

DocumentationFor clinical practice facilities need to follow the NPUAP 1. standards in regards to pressure ulcer documentation (i.e. Healing stage 4 that has the appearance of tissue size and depth of a stage 2- the clinical record will state a healing stage 4, but the MDS would have Stage 2 in M1.)

Document weekly assessments of the wound healing 2. progress or lack of. Documentation should include a thorough description of size, drainage, etc. Care planning should identify risk factors and interventions 3. based on the identified level of risk, as well as interventions to facilitate healing of existing skin problems.

ExampleMrs. B has impaired arterial circulation to her right foot. She has a Stage 3 in appearance on the top of her foot. She also has a 1. superficial skin tear on her right forearm. M1 would be coded as a Stage 3 ulcer, M2 would be coded with 0 (zeros) and M4a would be checked for the skin tear. M5d, e and g may be checked, depending on specified interventions. M6c would be checked.

M4. (See pg 3-159) Record the number of skin ulcers caused by either pressure or circulatory problems according to stage for M1. M2 is for coding the highest stage of pressure or venous stasis ulcers only.Include in M4 all skin problems not caused by pressure, 4. venous stasis, circulatory problems or not coded anywhere else in Section M.Code all skin treatments in M5.5. Code all foot problems and care in M6.6.

Directions for Pressure Ulcers: Facility Assessment Overview Questionnaire• Tobecompletedbyadirectcareorinterdisciplinaryteam.• Consultwithappropriatestaffinansweringcertainquestionsandcompletingchecklists.• Ifyouanswer“No”toanyofthequestionsbelow,pleaseproceedimmediatelytothechecklist

referenced by the page after the question. • Ifyouanswer“Yes”toaquestion,theprocessisalwayscompleteanddonesoconsistently.Please

continue to the next question. • Ifyouanswer“InProgress”toanyofthebelowquestions,theneedisbeingaddressedbutneedsimprovement.

A facility system assessment is a starting point for a quality improvement project. The checklists included in this booklet will be most useful if you take a critical look at your current practices.

When completing each checklist on the following pages:• Ifyouanswer“Yes”toallofthequestions,theprocessisalwayscompleteanddonesoconsistently.

Continuetothenextchecklist.• Ifyouarenotsure,oranswer“No”tooneofthequestions,chooseoneormoreelementsonwhichtofocus

yourqualityimprovement.• Ifyouanswer“NeedsImprovement”tooneormoreofthequestions,theprocessisnotalwayscomplete

and/ornotalwaysdoneconsistently.

Pressure Ulcers: Facility Assessment Checklists

Pressure Ulcers: Facility Assessment Yes No In Progress

Does your facility have a process to screen residents for pressure ulcer risk? (page 2) o o oDoes your facility have a process to develop and implement care plans for residents who have been found to be at risk or have a pressure ulcer? (pages 3-4)

o o o

Does your facility complete a comprehensive assessment for residents who are found to have pressure ulcers upon screening or, if there is no screening process in place, another time? (page 5)

o o o

For residents who have pressure ulcers, does your facility have a process for monitoring treatment and prevention? (page 6) o o o

Does your facility have a policy for pressure ulcer prevention and management? (page 7) o o o

Does your facility have initial and ongoing education on pressure ulcer prevention and management for all relevant staff? (page 8) o o o

A screening assessment is a brief assessment or question that determines if the resident is at risk for pressure ulcers. It does not include a thorough assessment of the pressure ulcer or what needs to be done if the resident is found to have a pressure ulcer upon screening.

Does your facility’s screening process include the following components?

Yes NoNeeds

ImprovementDo you screen all residents for pressure ulcer risk at the following times?

Upon admission o o oUpon readmission o o oWhen change in condition o o oWith each MDS assessment o o o

If resident is not currently deemed at risk, is there a plan to rescreen at regular intervals? o o oDo you use either the Norton or Braden pressure ulcer risk assessment tool? (If yes, STOP. If No, please continue to next question.) Note: Federal regulations (F-314) recommend the use of standardized risk assessment tools.

o o o

If you are not using the Norton or Braden risk assessment, does your screening address the following areas?Impaired mobility:

Bed o o o

Chair o o oIncontinence:

Urine o o o

Stool o o oNutritional deficits:

Malnutrition o o oFeeding difficulties o o o

Diagnosis of:Diabetes mellitus o o oPeripheral vascular disease o o o

Contractures o o oHx of pressure ulcers o o o

Completed by: _______________________________________ Date: ______________________________

Pressure Ulcers: Screening for Pressure Ulcer Risk

Pressure Ulcers: Facility Assessment Checklists: page 2

Does the resident care plan address the following interventions and risk factors (as they apply)?

Yes NoNeeds

ImprovementImpaired mobility

Assist with turning, rising, position o o oEncourage ambulation o o oLimit static sitting to 1 hour at any one time o o o

Pressure reliefSupport surfaces – bed o o oSupport surfaces – chair o o oPressure relieving devices o o oRepositioning o o oCheck for “bottoming out” in bed and chair (To determine if a patient has bottomed out, the caregiver should place his or her outstretched hand, palm-up, under the mattress overlay below the existing pressure ulcer or that part of the body at risk for pressure formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient has bottomed out.)

o o o

Nutritional improvementSupplements o o oFeeding assistance o o oAdequate fluid intake o o oDietician consult as needed o o o

Urinary incontinenceCause identified and treated as appropriate o o oToileting plan o o oWet checks o o oTreat causes o o oAssist with hygiene o o o

Fecal incontinenceCause identified and treated as appropriate o o oToileting plan o o oSoiled checks o o o

Skin condition checkCheck intactness o o oColor o o oSensation o o oTemperature o o o

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Pressure Ulcers: Developing Care Plans


Yes NoNeeds

ImprovementTreatment

Physician prescribed regimen o o oAppropriateness to wound staging o o oTreatment reassessment time frame o o o

PainScreen for pain related to ulcer o o oChoose appropriate pain med o o oProvide regular pain med administration o o oReassess effectiveness of med o o oAssess/treat side effects o o oChange, increase or decease pain med as needed o o o

InfectionDressing containment o o oKeep dressing dry/intact o o oAssess for s/sx infection o o o


Pressure Ulcers: Developing Care Plans



Does your comprehensive pressure ulcer assessment include the following components?

Pressure Ulcers: Assessment and Reassessment

Yes NoNeeds

ImprovementDo you have a tool available to document pressure ulcer assessment? o o oDoes your current assessment of pressure ulcers include:

Location o o oStage o o oSize o o oUndermining/tunneling o o oWound bed (tissue) o o oDrainage/exudate o o oPeri wound tissue (color, temp, bogginess, and fluctuation) o o oNeed for debridement o o o

Is the resident’s pressure ulcer reassessed:

Weekly o o oDaily if worsening or high risk o o o

Does reassessment include:

Size o o oTunneling o o oSinus tracts o o oPresence of necrotic tissue o o oExudate o o oGranulation o o oEpithelialization o o oColor photos, diagram, or drawing o o o

Are the following related factors considered in your assessment/reassessment:

Mechanical forces (shearing, friction, pressure) o o oPronounced bony prominences o o oPoor nutrition o o oAltered cutaneous sensation o o o



Does your facility’s process for monitoring treatment and prevention include the following?

Yes NoNeeds

ImprovementDoes your facility use a pressure ulcer tracking tool to document treatment and healing? (If “No,” skip to question 3.) o o oDoes the tracking form include the following:

Date o o oStage o o oCurrent treatment o o oColor photo, diagram, or drawing o o oSize o o oDepth o o oAppearance (e.g., redness, presence of discharge, eschar formation) o o o

Does your facility have protocols to follow if current pressure ulcer treatment is ineffective? o o o

Does your facility have protocols to follow if ulcers are found to be non-healing? o o oDoes your facility monitor pressure ulcers for the presence of infection (e.g., foul smell, greenish drainage, cellulitis, osteomyelitis)? o o oIs there a list of possible interventions for the resident at each level of risk (low, moderate, or high), that nursing staff may implement to prevent pressure ulcer development? o o oDoes your facility have a protocol for management of tissue loads (e.g., positioning, pressure relieving mattresses, dynamic mattress overlay)? o o oAre there adequate supplies to provide preventive interventions to all residents who require them (e.g., adequate pressure reducing or relieving mattresses/chair cushions)? o o o

Are pressure reducing or pressure relieving mattresses/chair cushions in good repair? o o oAre pressure reducing/relieving supplies available to staff on all shifts and whenever needed? o o oDoes your facility have protocols regarding pressure ulcer prevention that includes the following:

Monitoring residents for incontinence o o oNeed for assistance with mobility and bed mobility o o oWeight loss o o oNutritional deficiency o o oDehydration o o o


Pressure Ulcers: Monitoring Treatment and Prevention


Does the pressure ulcer elimination process include the following components?

Yes NoNeeds

ImprovementDoes your facility’s policy include a statement regarding your facility’s commitment to pressure ulcer prevention and management? o o o

Does your facility’s policy include screening, assessment, and monitoring of residents for pressure ulcers? o o o

Does your facility’s policy address measures that should be taken to prevent pressure ulcers in residents? o o o

If the resident is not currently deemed at risk, does your facility’s policy state that residents should be screened for pressure ulcer risk at regular intervals? o o o

Does your facility’s policy state that residents who are at risk for pressure ulcers be screened at the following times:

Upon admission o o oUpon readmission o o oWhen a change in condition occurs o o oWith each MDS assessment o o o

Does your facility’s policy state that residents at high risk for pressure ulcers should be screened daily? o o o

Does your facility’s policy include who, how, and when pressure ulcer program effectiveness should be monitored and evaluated?

Prompt assessment and treatment o o oSpecification of appropriate pressure ulcer risk and monitoring tools o o oSteps to be taken to monitor treatment effectiveness o o oPressure ulcer treatment techniques that are consistent with clinically-based guidelines o o oOptimize the resident’s ability to perform ADLs and participate in activities o o o

Does your facility’s policy address steps to be taken if pressure ulcer is not healing? o o oDoes your facility’s policy address a protocol for communication of reporting pressure ulcer staging/healing to the designated MDS personnel to ensure correct coding? o o o


Pressure Ulcers: Elimination


Does your facility’s training and education program include the following components?

Yes NoNeeds

ImprovementAre new staff assessed for their need for education on pressure ulcer prevention and management? o o o

Are current staff provided with ongoing education on the principles of pressure ulcer prevention and management? o o o

Does education staff provide discipline-specific education for pressure ulcer prevention and management? o o o

Is there a designated clinical “expert” available at the facility to answer questions from all staff about pressure ulcer prevention and management? o o o

Is the education provided at the appropriate level for the learner (e.g., CNA vs. RN)? o o oDoes the education include staff training on documentation methods related to pressure ulcers (e.g., location, stage, size, depth, appearance, exudate, current treatment, effect on ADL’s, pressure relieving devices used, nutritional support)?

o o o


Document available at www.primaris.orgMO-08-16-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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.

Pressure Ulcers: Staff Training and Education

Sample ProtocolImplementaprotocolandaccompanyingstrategiessuchasthosebelowtohelpguidethcareofresidentsatriskfordevelopingpressureulcers.

AtRisk

Moderate Risk

HighRisk

Very High Risk

Systematic skin inspection

Turn/reposition every 2 hours (if mobility impaired) or more often if needed

Turn/reposition every 2 hours and prevent direct contact between bony prominences

Protect heels

If bedfast, provide pressure-reducing support surface

If in wheelchair, provide pressure-reducing seat cushion

If appropriate, initiate remobilization program (therapy if appropriate, ambulation, stand-pivot transfers, restorative nursing etc)

Manage moisture (from incontinence)

Manage nutrition

Reduce friction/shear

Provide wedges/repositioning aids for 30 degree lateral positioning

Supplement turning schedule with small position shifts (hourly)

Obtain rehab assessment to:Determine need for pressure relief cushion•Assess correct seat height and w/c positioning•

Consider a pressure relieving support surface or powered mattress overlay

Written plan of care

Staff education

Sample Protocol: page 2


Sample risk reduction strategies:

Skin inspection: All residents should be inspected at least daily. This can be done with dressing, undressing, toileting, bathing, peri-care, etc. Pay particular attention to bony prominences. Minimize exposure to low humidity. Moisturize dry skin.

Turning and repositioning: Keep bony prominences from direct contact using systematic turning and repositioning and positioning devices such as pillows or foam wedges. Avoid positioning directly on the trochanter. Determine tissue tolerance.

Wheelchair Positioning: OT evaluate for proper fit to wheelchair and appropriate pressure relieving device. Reposition and off load eight hourly – stand if possible. Try to use at least three different chair types daily to alter pressure points. If residents are able, teach or cue them to shift their own weight every hour. Use a pressure-reducing device such as those made of foam, gel, air or a combination of the two. Do not use donut-type devices.

Heel Protection – Friction: To prevent friction, use “gripper” socks, sheepskin at foot of bed, transparent dressings or skin sealants, protective dressings (such as hydrocolloids), moisturizers

Heel Protection – Pressure: Keep ALL weight off residents’ heels. Elevate lower extremities with pillows length-wise under lower legs, multi-podus boots, heel-lift boots, loosen bed linens at foot of bed, foot cradle

Manage Incontinence: Initiate bowel/bladder program or scheduled toileting, incontinent care every two hours, incontinence barriers, briefs, absorbent underpads (made with materials that absorb moisture & present a quick drying surface to the skin), fecal bag (if frequent stools). Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness.

Manage Nutrition: Monitor for weight loss. Assess for chewing or swallowing problems. Provide a combination of: dietician consults, supplements, vitamin supplements, hydration, feeding assistance, adaptive equipment.

Reduce friction/shear: Draw sheet or lift pad for bed movement, trapeze, moisturize skin, limit head of bed elevation to 30 degrees (and only as required), long sleeve garments/elbow protectors, careful cleansing during incontinence/hygiene care, gait belt transfers (as appropriate), mechanical lift

Pressure relieving mattress/overlay: Pressure reducing mattress types include, foam, static air, alternating air, gel or water mattresses

Written plan of care: Each resident’s care plan should be unique, including specific turning and repositioning plans. Indentify and address each factor noted in the Risk Assessment.

Staff Education: Target prevention at all levels of health care, from providers to residents and families. Identify the role each plays in pressure ulcer prevention. Implement a comprehensive pressure ulcer prevention program.

References:Agency for Health Care Policy and Research (1994). Treatment of Pressure Ulcers. AHCPR Pub. No 95-0652.University of Iowa

Nursing Interventions Research Center. Prevention of Pressure UlcersAmerican Medical Directors Association. Pressure Ulcers in the Long-Term Care Setting Clinical Practice Guideline. Columbia, MD:

AMDA 2008Source: QIPMO: University of MO-Columbia, Sinclair School of Nursing, April 2008

Braden Scale for Predicting Pressure Sore Risk

page 1 of 2

NOTE: This form is copyrighted. Permission to reproduce this form may be obtained at no charge by accessing www.bradenscale.com/copyright.asp

ResidentName(Last,First,Middle)___________________________________________________________

Room#:_________ AttendingPhysician:_________________________DateofAssessment:_____________

Assess Date Evaluator signature/title Assess Date Evaluator signature/title

1 3

2 4

Assessment Date:

Risk Factor Score/Description 1 2 3 4

Sensory PerceptionAbility to respond meaningfully to pressure-related discomfort

1 = Completely Limited2 = Very Limited3 = Slightly Limited4 = No impairment

MoistureDegree to which skin is exposed to moisture

1 = Constantly Moist2 = Often Moist3 = Occasionally Moist4 = Rarely Moist

ActivityDegree of physical activity

1 = Bedfast2 = Chairfast3 = Walks Occasionally4 = Walks Freqeuently

MobilityAbility to change and control body position

1 = Completely Immobile2 = Very Limited3 = Slightly Limited4 = No Limitations

NutritionUsual food intake pattern1NPO: Nothing by mouth2IV: Intravenously3TPN: Total parenteral nutrition

1 = Very Poor2 = Probably Inadequate3 = Adequate4 = Excellent

Friction and Shear1 = Problem2 = Potential Problem3 = No Apparent Problem

Total Score

High Risk: Total score ≤ 12. Moderate Risk: Total score 13-14. Low Risk: Total score 15-16 if under 75 years old or 15-18 if over 75 years old

For Detailed Descriptions, see page 2

© Copyright Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission.


Sensory Perception1 = Completely Limited. Unresponsive (does not moan, flinch,

or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body.

2 = Very Limited. Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body.

3 = Slightly Limited. Responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

4 = No impairment. Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

Moisture1 = Constantly Moist. Skin is kept moist almost constantly by

perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

2 = Often Moist. Skin is often, but not always moist. Linen must be changed at least once a shift.

3 = Occasionally Moist. Skin is occasionally moist, requiring an extra linen change approximately once a day.

4 = Rarely Moist. Skin is usually dry; linen only requires changing at routine intervals.

Activity1 = Bedfast. Confined to bed.2 = Chairfast. Ability to walk severely limited or nonexistent.

Cannot bear own weight and/or must be assisted into chair or wheelchair.

3 = Walks Occasionally. Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4 = Walks Frequently. Walks outside room at least twice a day and inside room at least once every 2 hours during waking hours.

Mobility1 = Completely Immobile. Does not make even slight changes

in body or extremity position without assistance.2 = Very Limited. Makes occasional slight changes in body

or extremity position but unable to make frequent or significant changes independently.

3 = Slightly Limited. Makes frequent though slight changes in body or extremity position independently.

4 = No Limitations. Makes major and frequent changes in position without assistance.

Nutrition1 = Very Poor. Never eats a complete meal. Rarely eats more

than ½ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO1 and/or maintained on clear liquids or IV2 for more than 5 days.

2 = Probably Inadequate. Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding.

3 = Adequate. Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement if offered OR is on a tube feeding or TPN3 regimen, which probably meets most of nutritional needs.

4 = Excellent. Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

Friction and Shear1 = Problem. Requires moderate to maximum assistance in

moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.

2 = Potential Problem. Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3 = No Apparent Problem. Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

Braden Scale for Predicting Pressure Sore Risk: page 2

Resident: ___________________________________________________________ Date: _________________ThisformshouldbecompletedinconjunctionwiththeSkinRiskAssessment,inaccordancewithfacilitypolicy(onadmission,readmission,quarterly,andwithasignificantchangeincondition).Check“Yes”or“No”iftheitemreflectstheresident’sassessment.Iftheansweris“yes”tothreeormoreoftheitemslistedbelow,considerimplementationofthe“SkinTearPreventionProtocol.”

Skin Tear Risk Assessment

Skin Tear Risk Assessment Yes No Yes NoReduced mental status o o History of syncope or unsteady gait o oPoor nutritional status o o History of aggressive behavior o oHistory of skin tears o o Resistant to care o o

Dehydration o oBruises easily (If yes, total number of bruises:__________) o o

Self-abusive behavior o o Skin Tear Prevention Protocol To Be Implemented o o

Thin, translucent skin o o

Nurse Signature: __________________________________________ Date Protocol Initiated: __________________

When the Skin Tear Risk Assessment identifies that the resident is at risk for skin tears, the nurse will review this protocol and indicated pertinent interventions on the treatment record. The nurses on the unit, not the treatment nurse, manage this protocol, which includes:

Provide covering for legs, such as long pants, heavy stockings, 1. tube socks, or stockinetProvide covering for arms, such as, 2. stockinet, long sleeved shirts, or gowns.Application of Kling for arms or legs 3. ensuring no tape on skin.Send inappropriate clothing home with the family so that it is not put on the resident by mistake. If the 4. resident has no family, put the clothing in storage with the resident’s name on it.Re-evaluate the necessity of side rails and if still necessary5. pad the side rails on the bed. Care plan for potential isolation due to the use of padded side rails.Notify activities not to place the resident very close to another resident.6. Use two staff members for all care performed 7. as appropriate.If the resident becomes combative or resists care, stop the care and return after the resident calms down. 8. Try to identify what triggered the behavior. Adjust the care plan as necessary to include potential interventions.Provide lotion to the skin routinely.9. Assess the resident’s overall skin condition on a weekly basis – mark completion of this task on the treatment 10. record.Maintain hydration for the resident.11. Examine equipment (e.g. wheelchair, bed, bedrails) for sharp edges that could potentially harm the resident. 12. Notify maintenance if appropriate. Consult therapy in assisting with appropriate padding when necessary.Notify Dietician 13. to adjust diet as necessary.

Skin Tear Prevention Protocol

MO-08-08-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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. Adapted from Ratliff Care Center.


Related Federal Standard: “Quality of Care”Audit Objectives:To evaluate the application and use of the facility’s skin tear risk assessment.To evaluate the application and use of the facility’s skin tear prevention protocol.To identify that identified residents receive care based on the skin tear prevention protocol.Resident Sample: All residents in the facility who have received a risk assessment and residents that have been identified to be at

risk for developing skin tears.Audit Sample Size: _____ residents that were assessed for skin tear risk_____ residents that were placed on the skin tear prevention protocol

Time Period of Evaluation: __________________________________________through: ________________

Commencement Date of Study: ______________ Expected Completion Date of Study: ________________

Criterion No. Audit Criteria Exceptions Instructions for

Data Retrieval

1

The Skin Care Risk Assessment is used to assess for risk of skin tear:

Upon admissiona. Upon readmissionb. Each quarterc. With a significant change in statusd.

None Skin Care Risk Assessment

2

The Skin Tear Risk Assessment is complete:Resident namea. Total score is indicatedb. Indication if Skin Tear Protocol is to be implementedc. Date assessment completedd. Nurse’s signaturee.

None Skin Care Risk Assessment

3

If Prevention Protocol was indicated, it was implemented:Interventions were identified on the protocol forma. Interventions were placed on treatment recordb. Interventions were identified on care planc. Implementation date is indicatedd. Nurse’s signature is presente.

Residents at risk for skin care

Skin Care Prevention Protocol

Skin Tear Risk Assessment: page 2

Skin Tear Risk Assessment and Prevention Protocol—Audit

LTC Dehydration Risk Assessment

Resident Name: ____________________________________________________ Date: __________________Check all conditions that apply to this resident. The greater the number of items checked, the greater the risk for dehydration. Initiate a plan of care if necessary based on your findings. Medical Conditions/History:oDiabetesoCHFoCVAoDementiaoDepressionoMajor Psychiatric DisorderoRenal Diseaseo> 4 Chronic Conditions

History of:oRepeated infectionsoDehydrationoMalnutritionoConstipation Current Status:oAge ≥ 85oFemale genderoLanguage/speech difficultiesoCognitive Impairment oUnable to request fluids oUnaware of thirstoRecent change in mental statusoAny physical immobilityoRecent change in ability to carry out ADLsoRestraintsoFalling episodesoUrinary incontinenceoDecreased urinary outputoConstipation or diarrheaoCurrent fever and/or infectionoVomitingoRecent rapid weight loss (>3% / 30 days)oDraining woundoLethargy/weaknessoIncreased combativeness/confusionoReadmission from > 1 day hospital stayoLab/Studies involving NPO or dyes

Medications:o≥ 4 medicationsoDiureticsoLaxativesoSteroidsoACE inhibitorsoPsychotropics/antipsychoticsoAntianxiolyticsoTricyclic Antidepressants or Lithium Intake Ability StatusoSwallowing difficultiesoRefuses fluidsoDislikes fluids/foods offeredoFluid restrictionoRequires assistance to eat/drinkoPoor eater (eats < 50% of each meal)oHolds food/fluid in mouthoDroolsoSpits out food/fluidoSpills fluidsoTube fedoIV fluid therapy Laboratory Abnormalities:

(or steady increase even if within normal range)oUrine Specific GravityoUrine color dare yellow > 4oBUN/Creatinine > 20:1 -or- o in BUN + stable Creatinine leveloSerum SodiumoSerum OsmolalityoHematocrit > normaloBMI < 2 or > 27 Knowledge Issues:oLack of understanding about fluid needsoLack of understanding about causes of dehydrationoCultural barriers about hydration, reporting thirst, end

of life issues


MO-08-05-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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.

Comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Nurse’s Signature: __________________________________________________________________________

Resident: _______________________________________________ Date:_____________________________ Performavisualassessmentofaresident’sskinuponadmission.Reportanyareasofconcerntothechargenurseimmediately.Forwardanyareasofconcerntothenextshift.InitiateaplanofcaretoaddresstheproblemandalerttheCNAs.Usethisformtoshowtheexactlocationanddescriptionoftheabnormality.Usingthebodychartbelow,describeandchartallabnormalitiesbynumber.

MO-06-07-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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. Adapted from Ratliff Care Center.


Comprehensive Admission Skin Assessment

Nurse Signature: ________________________________________________________ Date: ____________________

Indicate on the body chart any areas of concern:A = Abrasion(s) ST = Skin Tear(s)

B = Bruise(s) SU = Stasis Ulcer(s)

PU = Pressure Ulcer(s) SW = Surgical wound(s)

S = Scar(s) O = Other

Narrative Note: Note site, length, width, depth, drainage, odor, pain and any other defining characteristics.

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Performavisualassessmentofaresident’sskinwhengivingtheresidentashower.Reportanyabnormallookingskin(asdescribedbelow)tothechargenurseimmediately.ForwardanyproblemstotheDONforreview.Usethisformtoshowtheexactlocationanddescriptionoftheabnormality.Usingthebodychartbelow,describeandgraphallabnormalitiesbynumber.

Resident: _______________________________________________ Date:_______________________

MO-08-42-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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. Adapted from Ratliff Care Center.


Skin Monitoring: Comprehensive CNA Shower Review

Visual Assessment 1. Bruising 2. Skin tears 3. Rashes 4. Swelling 5. Dryness 6. Soft heels 7. Lesions 8. Decubitus 9. Blisters 10. Scratches 11. Abnormal color12. Abnormal skin 13. Abnormal skin temp (h-hot/c-cold) 14. Hardened skin (orange peel texture) 15. Other: _________________________

CNA Signature: _________________________________________________________ Date: ____________________

Does the resident need his/her toenails cut?

Yes No

Charge Nurse Signature: _________________________________________________ Date: ____________________

Charge Nurse Assessment: ___________________________________________________________________________

_________________________________________________________________________________________________

Intervention: ______________________________________________________________________________________

_________________________________________________________________________________________________

Forwarded to DON:

Yes No

DON Signature: _________________________________________________________ Date: ____________________

Skinchecksaretobecompleteddailyforresidents.AgoodtimetodothemisduringAMandPMcareandduringbathingtime.Listtheresidentname,typeandsite(aslistedbelow)ofobservedimpairedskinintegrity.

MO-08-43-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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.

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Staff Name: _____________________________________________ Completion Date:___________________


Diagram KeyTypes Sites• Bruises(B) • Ears,RTorLT(E)• Skintears(ST) • Shoulders(S)• Pressureulcers(PU) • Arms(A)• Scabs(S) • BackofHead(H)• Other(O) • Coccyx(CO) • Legs(L) • Shin(SH) • Knees(K) • Feet(F) • Heels(HE) • Hands,front(HF) • Hands,back(HB) • Other(O)

Resident Name Type Site

Skin Monitoring: Daily Skin Check

Syst

ems

Inve

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Pre

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Trea

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ulce

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MO

-08-

17-P

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This

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Pressure Ulcer Prediction, Prevention and Treatment Pathway


Step One: Assess Skin Condition

Resident is admitted or readmitted to SNF

Does the resident have a pressure ulcer?

Overall Skin Condition DocumentationColor•Temperature•Moles•Bruises•

Incisions•Scars•Intact skin•Burns•

Report findings to physician

Obtain treatment order from

physician

Notify Family

Turn pageGo to Step 2

Pressure Ulcer DocumentationLength•Width•Depth•Location•Stage•Exudate•

Tunneling•Necrosis•Granulation•Undermining•Sinus tracts•Pain•

Remember, if a patient is at risk or has a pressure ulcer, repeat Step One on a weekly basis.

Head-to-toe skin assessment (upon admission and weekly)

Yes No

Report anything abnormal to physician

Notify Family

Turn pageGo to Step 2

Obtain treatment order from physician if

appropriate

Yes

Yes

Yes

Yes

Pressure Ulcer Prediction, Prevention and Treatment Pathway

Document available at www.primaris.orgMO-08-52-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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.

Step Two: Complete Risk Assessment to Identify Risk Factors and Care Plan Interventions

At Risk?

Remember that those with a pressure ulcer are automatically at risk.Repeat skin risk assessment at least every 90 days

and significant change or per facility protocol

Care Plan Actual Skin Problem Care Plan Potential Skin Problem

Complete Care Plan Problem Statement

Skin integrity, impaired, actual as evidenced by (AEB) (Wound-specific description: Location, stage, and measurements)related to (R/T) identified risk factors

Complete Care Plan Problem Statement

Potential for impaired skin integrity, as evidenced by (AEB), risk assessment indicates that the resident is at risk for skin breakdown related to (R/T) identified risk factors

BedT/R schedule•Pressure reducing/relieving •deviceTherapy consult•

ChairRepositioning schedule•Pressure-relieving cushion•Assessment of chair fit•

Friction/ShearPadding to prevent skin contact•Booties/heel protectors, elevate heels•HOB in lowest position possible, unless contraindicated by •medical conditionPositioning devices•

Does the resident have a pressure ulcer?

IncontinencePeri care after each incontinence•Clean as soon as possible after soiling•Barrier cream•Incontinent pads, incontinent briefs•

MoistureRemove incontinence •brief while in bedMoisture barrier•

OtherAdd any/all interventions related to identified specific risk factors•

Bed/ChairMobility

B/BIncontinence

andMoisture

NutritionandBodyWeight

OtherResident-

specificRiskFactors

Frictionand/orShear

Yes

Yes No

No

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No

No

Yes

Possible Care Planning InterventionsAddress Possible Risk Factors

Perform Step Two at least every 90 days and with any significant change. Adjust care plan as needed.

Complete Skin Risk Assessment

No

Nutrition and body weightWeekly weight•Dietician consult•Labs•Food •SupplementsSpeech therapy•

Vitamin/medication supplements•Hydration•Feeding assistance•Assessment for chewing and swallowing •problems

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Managing Tissue Loads

Document available at www.primaris.orgMO-08-12-PUH August 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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.

Appropriate Patient Positioning

Reevaluate plan of care Monitor

Patient atrisk for additional

ulcers?No special surface needed

Use device that moves air across skin

Dynamic overlay or mattress

Air-fluidized bed

Multiple large, truncal Stage III

or IV ulcers?

Able to keep ulcer off

surface?

Skinmoistureproblem?

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available?

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out?

Ulcerhealing

properly?

Low air-loss bed

Ulcerhealing

properly?

Monitor

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Ulcerhealing

properly??

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

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Ulcerhealing

properly?

YesNo

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No

No

No

No No

No

No

No

No

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out?

Key Yes/NoDecisions Interventions

Reference: Quick Reference for Clinicians No. 15Page 10 Developed by AHCPR

Support Surfaces: Characteristics and Considerations

Specialty Beds

Air-fluidized bed (also known as a “bead bed” or “sand bed ”) Product Characteristics: This is a bed frame containing silicone-coated beads incorporated in Gortex® covering. When air is pumped through the beads, they behave like a liquid, creating air and fluid support. The resident “floats” on a sheet with one third of the body above the surface and the remainder of the body immersed in the warm, dry, fluidized beads. When bed is turned off, the surface becomes firm to allow for repositioning. Helps manage copious wound drainage or incontinence by absorbing fluids into bed of silicone beads. Although there is some evidence that air-fluidized beds enhance pressure ulcer healing rates, surface interface pressure remains sufficiently high to occlude capillary perfusion. Occipital and heel ulcers have been reported to develop in patients while on an air-fluidized bed (Parish & Witkowski, 1980).Considerations:

Not recommended for mobile patients, patients with pulmonary disease or patients with unstable spine•Continuous circulation of warm, dry air may dehydrate patient or desiccate wound bed•Bed may get too hot or make room hot•Head of bed cannot be raised; semi-Fowler’s position achieved by using foam wedges or movable sling-type device•Coughing less effective in mobilizing secretions•Leakage of beads may irritate the eyes and respiratory track and make floor slippery•Width of bed may preclude care to obese patients or patients with a contracture•Height of bed makes some nursing care difficult, and a step is needed to facilitate care•Transfer of patient out of bed is difficult•Bed is heavy and not easily transferable•Some patients become disoriented or complain of feeling weightless while on surface•Dependent drainage of catheters may be compromised because the patient is immersed in the bed•Sharp objects may damage the surface•Size and weight may be too large for use in home setting•

Set up and maintenance provided by company•

Low air-loss bedProduct Characteristics: A bed frame with a series of connected air-filled pillows that can be calibrated for varying amounts of pressure to provide maximum pressure reduction for residents. Dry air flow between the patient and bed surface helps control moisture and heat buildup and prevents maceration and friction. Some models are designed to counteract the effects of immobility on pooling of respiratory secretions and urinary stasis by providing oscillation therapy. Other models feature kinetic therapy (rotating slowly side to side), although this is limited to a 20-degree rotation and does not have the same effect as manually rotating the resident side-to-side.Considerations:

Head and foot of bed can be raised and lowered•Transfers in and out of bed easily accomplished•Portable motor available to maintain inflation during bed transfers.•

Motor may be noisy•Proper inflation essential to maintain effectiveness• Sharp objects may damage the surface•

Bed surface is slippery; patients may slide down or out of bed with being transferred•Heels need to be “floated” to totally relieve pressure•

Set up and maintenance provided by company•

Dynamic Overlays

Alternating air-filled overlayProduct Characteristics: Air is pumped through overlay chambers at regular intervals to provide cyclical pressure changes, creating a low-pressure and a high-pressure area. These surfaces constantly change pressure points and create pressure gradients that enhance blood flow. Cells with larger diameter and depth produce greater pressure relief over the body. A cell depth of not less than 3 inches is recommended. Considerations:

Surface is easy to clean•Assembly required•Sensation of inflation and deflation may bother patient•Electricity required•Motor may be noisy•Excessive or sudden surface movement may disturb sleep•Sharp objects may damage the surface•Bed surface is slippery; patients may slide down or out of bed with being transferred•Heels need to be “floated” to totally relieve pressure•

Static Overlays

Foam OverlayProduct Characteristics: A foam surface applied over the surface of an existing hospital mattress. The following characteristics of foam influence the effectiveness of the overlay: base height, density and indentation load deflection (ILD). Base height refers to the height of the foam from the base to where the foam ridges begin and should be 3 to 4 inches to be effective in reducing pressure. Density refers to the weight per cubic foot and reflects the foam’s ability to support the person’s weight. Foam densities of 1.3 to 1.6 pounds per cubic foot are generally effective in supporting an average size adult. ILD is a measure of the firmness of the foam. It describes the foam’s compressibility and conformability. It also indicates the ability of the foam to distribute the mechanical load. Measurement of ILD is expressed as the number of pounds required to indent a sample of foam with a circular plate to a depth of 25% of the thickness of the foam. An ILD of approximately 30 pounds is recommended. Optimal support and conformability of foam is achieved when the relationship between 60% ILD and 25% ILD is 2.5 or greater (Krouskop & Garber, 1987; Whittemore, 1998). Considerations:

Plastic protective sheet is usually required for incontinent patients•Foam may trap perspiration and be hot•Washing removes flame-retardant coating•One-time charge, no reoccurring charges•No set up or maintenance fees•Cannot be punctured by needle or metal traction•Light weight•

Support Surfaces: Characteristics and Considerations: page 2


Requires no maintenance•No electricity required to operate•May be hot and trap perspiration•Foam has a limited life•Lack of firm edge creates unsure surface when patient transferring on and off surface•Heels need to be “floated” to totally relieve pressure•Must be discarded when wet from drainage or incontinence•Adds height to the bed•

Air OverlayProduct Characteristics: Interconnected bubble-like cells that are inflated with an air blower to an appropriate pressure level. Optimum air level is defined as 1 inch or more of uncompressed support surface between bony area of the resident’s body and the caregiver’s hand when placed under the support surface. Cells with larger diameter and depth produce greater pressure relief over the body. A cell depth of 3 in. or greater is recommended. Considerations:

Easy to clean•Low maintenance•Repair of some products is possible•Durable•Can be damaged by sharp objects•Requires regular monitoring to determine proper inflation and need for reinflation•Heels need to be “floated” to totally relieve pressure•Adds height to bed•Lacks a firm edge, so transfer on and off surface may be difficult•

Water OverlayProduct Characteristics: A vinyl chamber that can be filled with water to appropriate level to distribute body weight evenly over the entire supporting surface. Recommended depth is 3 in. or greater. Some models contain a baffle system to control motion effects.Considerations:

Readily available in the community• Easy to clean• Requires water heater to maintain comfortable water temperature• Fluid motion makes procedures difficult (e.g. positioning)• Patient transfers may be difficult• Inadvertent needle punctures will create leaks• Maintenance is needed to prevent microorganism growth• Surface is heavy• Cannot raise head of bed unless mattress has compartments•Can be overfilled (causing too firm a surface) or underfilled (decreasing pressure reducing benefit)•


Gel Overlay Product Characteristics: A pad constructed of Silastic, silicone or polyvinyl chloride. Lack air-flow for moisture control and friction control is variable depending on the surface of the gel. Recommended depth for effective support is 2 in. or more. Gel filled pads are particularly useful in wheelchairs.Considerations:

Low maintenance• Easy to clean• Multiple-patient use• Impermeable to punctures with needles• Surface is heavy• Expensive purchase price•Heels need to be “floated” to totally relieve pressure• Research on effectiveness is limited•

Some surfaces may be slippery; patient may slide down or out of bed during transfers•

Replacement MattressProduct Characteristics: Mattress made of foam and gel combinations or layers of different foam densities. Some models have replaceable foam shapes and some have a replaceable foam core. Other replacement mattresses contain a series of air-filled chambers covered with a foam structure. All models are covered with a comfortable, water-repellent, bacteriostatic cover that can be maintained with routine cleaning. Mattresses with foam should be antimicrobial and have appropriate foam ILD with high resiliency. Evidence is increasing that replacement mattresses are superior to standard hospital mattresses and may be more effective than some overlays (Vyhlidal, et al., 1997). Considerations:

Reduce use of overlay mattresses•Reduce staff time•Do not add height to mattress•Provide certain level of pressure reduction automatically•Multiple-patient use•Easy to clean•Use standard hospital linens•Low maintenance•Initial expense is high•Some mattresses have removable sections which may be misplaced•May not control moisture•Potential for excessive delay in using other support surface•No objective method for determining when or if product loses effectiveness•Life of product is not known •


Additional References:Hess, CT: Wound care, Springhouse, Pennsylvania, 2000, Springhouse Corporation.

Krouskop TA, Garber SL: The role of technology in the prevention of pressure sores, Ostomy & Wound Management, 16:45, 1987.

Maklebust J, An Update on Horizontal Patient Support Surfaces. Ostomy & Wound Management, 45, No 1A (suppl) 70S to 77S, 1999.

Maklebust J, Sieggreen M: Pressure ulcers guidelines for prevention and management, Pennsylvania, 2001, Springhouse Corporation.

Parish IC, Witkowski JA: Clinitron therapy and the decubitus ulcer: preliminary dermatologic studies, Dermatology, 19:517, 1980.

Vyhlidal S et al: Mattress replacement or foam overlay? A prospective study on the incidence of pressure ulcers, Applied Nursing Research, 10(3):111, 1997.

Whittemore, R. Pressure reduction support surfaces: A review of the literature. JWOCCN, 25:6-25. 1998.

Document available at www.primaris.orgMO-08-48-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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.

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Policy:

This sample procedure is to help enhance the healing of pressure ulcers by the use of nutritional intervention whenever possible. These are guidelines only and individual patient and resident needs must be taken into consideration before implementation.

Procedure:

The nursing department reports all pressure ulcers and their stage to food and nutrition services.•The available dietician is contacted and reviews each case to make an individualized nutrition care plan.•Food and nutrition services may implement the following interventions, based upon the stage of resident’s •pressure ulcers. Note that vitamin and mineral supplementation would require a physician’s order.

Stage 1: » 4 Vitamin C-rich food, high protein afternoon snack and a daily MVI with mineralsStage 2: » Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day and MVI with minerals dailyStage 3: » 8 oz. Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day, high-protein snacks twice a day and MVI with minteralsStage 4: » 8 oz. Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day, high-protein snacks three times a day and MVI with minerals

Other nutritional considerations:

Think about other options to enhance nutritional status, such as:•Increase eggs, milk, meat and cheese for additional HBV protein »

Add protein powder to foods »

Add other foods high in Vitamin C if the resident or patient dislikes orange juice »

Use Arginaid powder in place of Arginaid Extra if the patient is obese »

Continue nutritional interventions until wound has been healed for two weeks•Avoid zinc supplementation for more than two months at a time•Goal caloric intake is 30-35 kcal per kg or BMR x 1.5 stress factor x 1.2 (bed) or 1.3 (out of bed)•Goal protein intake with no renal considerations is as follows:•

Stage 1: » 1.2-1.4 g. per kg.Stage 2 » : 1.4-1.6 g. per kg.Stage 3: » 1.6-1.8 g. per kg.Stage 4: » 1.8-2 g. per kg.

Goal of fluid is 30-35 ml. fluid per kg.•If on chronic antibiotic use, give yogurt or lactobacillus supplements•If patient/resident has a compromised gut (intestinal mucosal atrophy or malabsorbtion from malnutrition, •10-20 mg. of glutamine supplementation should be considered

Nutritional Wound Healing Guidelines


Note: 8 oz. Arginaid Extra provides the following: 10 g. protein, 250 calories, 20 mg. zinc, 1,000 IU vitamin A, 250 mg. vitamin C; MVI with minerals usually contain the following amounts: 15 mg. zinc, 3,500 IU vitamin A, 60 mg. vitamin C, 18 mg. iron and 2 mg. copper

Selected Characteristics of Support Surfaces


Selected Characteristics for Classes of Support SurfacesSupport Devices

Performance characteristics Air-fluidized Low Air-lossAlternating

AirStatic Flotation

(air or water) FoamStandard Mattress

Increased support area Yes Yes Yes Yes Yes No

Low moisture retention Yes Yes No No No No

Reduced heat accumulation Yes Yes No No No No

Shear reduction Yes ? Yes Yes No No

Pressure reduction Yes Yes Yes Yes Yes No

Dynamic Yes Yes Yes No No No

Cost per day High High Moderate Low Low Low

Chair Support SurfacesSupport Surface Characteristics Cost Concerns

Foam Cushion Provides some pressure reduction, •depending upon the thickness of the foam (a thickness of no less than four inches is recommended)Resident still requires repositioning at •least every hour

Low Cost After laundering, this surface is no longer •useful for pressure reduction. A slip cover that can be separately laundered keeps the cushion clean and dry

Gel Cushion Reduces pressure by spreading pressure •across the contact surfaceDoes not replace repositioning•

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Air-filled Cushion Reduces pressure by evenly distributing •weightCells fill with air and deflate as pressure is •applied. Does not replace repositioning

High Cost Compromised integrity can render this •product ineffective. An ineffective air-filled cushion should be replaced

Reference: Quick Reference Guide for Clinicians, No. 15, page 11. Developed by the Agency for Healthcare Research and Quality (AHRQ).

SituationResident Name: _____________________________________________Age: ________ Admit Date: ______________Admitting physician/consulting physician: _____________________________________________________________Diagnosis/reason for admission: _____________________________________________________________________Treatment plan: __________________________________________________________________________________

Background (check all that apply)Past medical history: ______________________________________________________________________________Allergies: _______________________________________________________________________________________Diet type: _____________________________ q NG/G-tube feedings q TPN/PPN q Ostomy/drains q Foley

Medication Medication

Assessment (check all that apply)q Pressure ulcer present q Precautions:___________ q Completely immobile q Limited mobility q Fully mobileq Incontinent q Impaired sensation q Alert/oriented q Confused q Lethargic/unresponsive q Photos taken

Braden Score:_______q High Riskq Low Riskq No Risk

Decubitus KeyStage I: Red/skin intactStage II: Superficial breakdownStage III: Skin breakdown Sub Q involvedStage IV: Skin breakdown. Muscle/bone exposed*Do no stage if base of wound not visible

Site Diagram

Date Site # Stage Size (in cm) Description (color, drainage, odor, sloughing, eschar, undermining)

Recommendation (check all that apply)

Pressure Ulcer Prevention Measuresq Keep clean and dry q Avoid diaper/brief useq Apply cleanser/barrier lotions to ________ every ____ hoursq Apply Nystatin powder to _____________ every ____ hoursq Use special bed/mattress (specify type): ____________q Turn and reposition patient every ______ hoursq Use chair cushion (specify type): _________________q Elevate heels q Use heel protectors/heel liftq Use elbow protectors q Dietary/nutrition consultq Other: ______________________________________

Pressure Ulcer Managementq Ulcer treatment: ______________________________q Dressings (specify type and frequency): ____________ ___________________________________________q Wound vac: __________________________________q Consider Foley catheter: ________________________q Odor control: ________________________________q Dietary/nutrition consultq Other: ______________________________________ ___________________________________________

Comments: _____________________________________________________________________________________ ____________________________________________________________________________________________Assessment and recommendations completed by (signature) _______________________ Date: _______________Treatment protocol approved by (signature) _____________________________________ Date: _______________

SBAR: Skin Care Instructions


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(SUSPECTED) DEEP TISSUE INJURY Purple or maroon localized area of discolored intactskin or blood-filled blister due to damage of underlyingsoft tissue from pressure and/or shear. The area maybe preceded by tissue that is painful, firm, mushy,boggy, warmer or cooler as compared to adjacent tis-sue.

Further Description: Deep tissue injury may be diffi-cult to detect in individuals with dark skin tones.Evolution may include a thin blister over a dark woundbed. The wound may further evolve and become cov-ered by thin eschar. Evolution may be rapid exposingadditional layers of tissue even with optimal treatment.

STAGE IIntact skin with non-blanchable redness of a localizedarea usually over a bony prominence. Darkly pig-mented skin may not have visible blanching; its colormay differ from the surrounding area.

Further Description: The area may be painful, firm,soft, warmer or cooler as compared to adjacent tissue.Stage I may be difficult to detect in individuals with darkskin tones. May indicate “at risk” persons (a heraldingsign of risk).

STAGE IIPartial thickness loss of dermis presenting as a shallowopen ulcer with a red pink wound bed, without slough.May also present as an intact or open/ruptured serum-filled blister.

Further Description: Presents as a shiny or dry shal-low ulcer without slough or bruising.* This stageshould not be used to describe skin tears, tape burns,perineal dermatitis, maceration or excoriation.

*Bruising indicated suspected deep tissue injury.

STAGE IIIFull thickness tissue loss. Subcutaneous fat may be vis-ible but bone, tendon or muscle are not exposed.Slough may be present but does not obscure the depthof tissue loss. May include undermining and tunneling.

Further Description: The depth of a stage III pres-sure ulcer varies by anatomical location. The bridge ofthe nose, ear, occiput and malleolus do not have sub-cutaneous tissue and stage III ulcers can be shallow. Incontrast, areas of significant adiposity can developextremely deep stage III pressure ulcers. Bone/tendonis not visible or directly palpable.

STAGE IVFull thickness tissue loss with exposed bone, tendon ormuscle. Slough or eschar may be present on someparts of the wound bed. Often include underminingand tunneling.

Further Description: The depth of a stage IV pres-sure ulcer varies by anatomical location. The bridge ofthe nose, ear, occiput and malleolus do not have sub-cutaneous tissue and these ulcers can be shallow. StageIV ulcers can extend into muscle and/or supportingstructures (e.g., fascia, tendon or joint capsule) makingosteomyelitis possible. Exposed bone/tendon is visibleor directly palpable.

UNSTAGEABLEFull thickness tissue loss in which the base of the ulceris covered by slough (yellow, tan, gray, green orbrown) and/or eschar (tan, brown or black) in thewound bed.

Further Description: Until enough slough and/oreschar is removed to expose the base of the wound,the true depth, and therefore stage, cannot be deter-mined. Stable (dry, adherent, intact without erythemaor fluctuance) eschar on the heels serves as “thebody’s natural (biological) cover” and should not beremoved.

Pressure Ulcer Definition and StagesPressure Ulcer Definition and StagesPressure Ulcer Definition and Stages

Updated 02/2007 Copyright © 2007

PRESSURE ULCER STAGESDEF IN ITION

A pressure ulcer is localizedinjury to the skin and/orunderlying tissue usuallyover a bony prominence, as a result of pressure, orpressure in combination with shear and/or friction.

A number of contributing or confounding factors arealso associated with pressureulcers; the significance of these factors is yet to be elucidated.

Pressure ulcers are stagedusing the system at right.

This staging system should be used only to describe pressure ulcers. Wounds from other causes, such asarterial, venous, diabetic foot, skin tears, tape burns, perineal dermatitis, maceration or excoriation should not bestaged using this system. Other staging systems exist for some of these conditions and should be used instead.

National Pressure Ulcer Advisory Panel1255 Twenty-Third Street NW, Suite 200Washington, DC 20037T: 202-521-6789F: 202-833-3636www.npuap.org

Pressure Ulcer Classifications

Suspected Deep Tissue InjuryPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Further descriptionDeep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue, even with optimal treatment.

Stage 1 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.

Further descriptionThe area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).

Stage IIPartial 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.

Further descriptionPresents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

*Bruising indicates suspected deep tissue injury

Pressure Ulcer Classifications

Stage IIIFull 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.

Further descriptionThe depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Source: National Pressure Ulcer Advisory Panel, Pressure Ulcer Stages Revised, February 2007. Permission to use granted to Primaris, the Quality Improvement Organization for Missouri.

Stage IV 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.

Further description The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. 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.

UnstageableFull 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.

Measuring Wounds Measure the length “head to toe” at the longest point (A) and the width at the widest point (B). Measure the depth (C) at the deepest point of the wound. All measures should be in centimeters.

Documentation and Measuring

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Tunneling/Sinus Tract UnderminingA narrow channel of passageway extending into healthy tissue.

Tunneling wound which begins directly under the wound edge.

Using a clock format, descrive the location and extent of tunneling (sinus tract) and/or undermining.

Wound locationStageSize

Length•Width•Depth•

Tunneling/Sinus TractUndermining

Necrotic TissueSlough•Eschar•

Granulation

Pressure ulcer documentation includes

PainExudate/Drainage

Amount•Color •Odor•

Description of Surrounding TissueSupport SurfaceWound edges

Round•Rolled•Extended•

Note the following skin characteristics

Color•Temperature•Moles•Bruises•

MO-08-49-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, and adapted from LHCR. The contents presented do not necessarily reflect CMS policy.

Incisions•Scars•Intact•Burns•

Pressure Ulcers: CNA Knowledge & Attitude Survey

Weareinterestedinyourindividualanswer.Pleasechecktheboxtoindicate“True”or“False”foreachofthefollowingstatements.

PositionTitle:_____________________________________________________________________________Department:_______________________________Shift(checkone):o Days o Evenings o Nights

PressureUlcers:CNAKnowledgeandAttitudeSurvey True False1. Identification and reporting of reddened or open areas of skin are part of my job. o o2. Pressure ulcer prevention is part of my job. o o3. Pressure ulcers should only be documented by RN or LPN staff members. o o4. Immobility is a cause of pressure ulcers. o o5. Incontinence is a cause of pressure ulcers. o o6. Poor dietary intake is a cause of pressure ulcers. o o7. Chronic illness is a cause of pressure ulcers. o o8. Poor circulation is a cause of pressure ulcers. o o9. Pressure ulcers are part of the aging process. o o

10. Pressure ulcers can be prevented by proper positioning of residents. o o

11. Pressure ulcers begin with a reddened area of the skin that does not disappear after pressure is relieved. o o

12. Residents who have had a pressure ulcer in the past are more likely to develop one in the future. o o

13. A bed ridden resident will not fully recover from a pressure ulcer without surgery. o o

14. Pressure ulcers are often viewed as a sign of poor care being provided by the nursing staff. o o

15. Pressure ulcers lower a resident’s self-esteem. o o16. Pressure ulcers can occur on any area of the body. o o

CNA Knowledge and Attitude Survey ResultsA Guide to ActionAsk staff to complete the CNA Pressure Ulcer Knowledge and Attitude Survey. Then, use the following as an answerkeyandaguidetoaction.You’llnoticethatparticularanswersmaybe“True”forsomestaffand“False”for others. This sheet will show how you might revise overall nursing home practices to improve staff knowledge and residents’ care.

Questions 1 & 2All nursing home clinical staff should have identification, assessment, prevention, care and documentation of pressure ulcers identified as a part of their job duties. If your staff felt this statement was “False,” this may be an area you could focus on for additional training.Non-clinical staff’s answers may vary between “True” and “False.” If you have non–clinical staff who feel that prevention is not part of their job, consider additional training. It is important for all staff to recognize ways they can identify potential problems and inform appropriate clinical staff. Ideas for improvement:

Explain how and why you’re committed to pressure ulcer prevention and treatment•Describe you home’s overall pressure ulcer plan•Describe each team member and family member’s role in pressure ulcer prevention assessment and treatment•

Question 3This question addresses pressure ulcer documentation. All staff is responsible for noting information as a part of the general pressure ulcer plan of care. Leaders must instruct how and where that information will be documented on the resident’s record. Non-clinical staff may answer “False,” but you need a process for non-clinicians to report their observations as well, ensuring this information is documented. Ideas for improvement:

Define pressure ulcer documentation guidelines for all disciplines. •Offer training on sharing work responsibilities among disciplines. For example, activities staff must •reposition resident while attending activities and document this for staff sharing, dietary staff must know the resident with a pressure ulcer cannot sit up to eatIdentify pressure ulcer tools to increase documentation consistency throughout the facility and within •clinical staff. For example: ulcer measurement guide, bedside turning schedule, staging guidelines or exudate documentation

Questions 4, 5, 6, 7, 8 and 12 These question reference risk factors for pressure ulcer formation. Immobility, poor nutrition, incontinence and circulatory conditions are all risk factors. If your facility’s surveyed staff felt any of these statements were “False,” it may indicate that the pressure ulcer riskfactorsarenotwellknownortheirimportanceisnotwellunderstood.Youmaywanttoidentifyifonegroup of employees or employees in general need information regarding risk factors and the role they play in pressure ulcer formation. Questions to ask staff:

What are the identified pressure ulcer risk factors?•How do risk factors contribute to the formation of pressure ulcers?•When are residents assessed for risk factors in your facility?•What effect do risk factors have on residents’ plan of care?•

Pressure Ulcers: CNA Knowledge & Attitude Survey: page 2

Who is responsible for identification and care planning for residents with identified risk factors?•Why is this important? •

Question 9This question addresses a common misconception. Pressure ulcers are not part of the normal aging process. Although loss of skin elasticity and thinning of the skin are normal with aging, pressure ulcer formation is not. If most of your staff answered “True” to this survey question, you need to provide them with information about the normal aging process, including:

How the factors of the normal aging process contribute to the risk for pressure ulcer formation.•What your facility is doing to address the care associated with the elderly. For example, nutritional and •activity programs, support groups, association with community support group.Yourfacility’seffortstocommunicatewithotherhealthcarefacilitiesthatyouhavedirectinteractionwith,•i.e. referring hospitals, senior citizen groups, physician’s offices, home health agencies.

Question 10This question addresses the role of proper positioning in pressure ulcer prevention. If the lower extremity were positioned with proper support to keep pressure off the heel, an ulcer due to pressure on the heel would be prevented. If staff felt positioning did not contribute to pressure ulcer prevention, as noted with a “False” answer, consider:

Instruction on and demonstration of basic positioning techniques. •Reviewing your home’s resident care plans to address proper positioning and repositioning, i.e. turning •schedule, pressure reduction techniques, devices available at your facility to reduce pressure load.Reviewing of the etiology of pressure ulcer formation with staff, such as prolonged pressure reducing the •blood flow to the capillaries causing tissue damage.

Question 11 This question addresses pressure ulcer development. Pressure ulcers begin with a reddened area of the skin that does not disappear after the pressure is relieved. This is identified as a Stage I pressure ulcer. A response of “False” to this question indicates your staff doesn’t have a good understanding of pressure ulcer formation. Consider the following actions:

Provide all staff with common consistent definitions of pressure ulcer stages, such as guidelines from the •National Pressure Ulcer Advisory Panel.Adopt standard facility procedures for describing, measuring and evaluating pressure ulcers.•Provide consistent tools – such as measurement guides and an assessment scale – throughout the home for •staff to use consistentlyReview and adapt your pressure ulcer plan of care •

Question 13 This question identifies the misconception that a bed-ridden resident’s pressure ulcer requires surgery to heal. Improved wound care products and pressure reduction devices have greatly increased the healing of pressure ulcers without surgical interventions. If staff responded “True,” to this statement, consider:

Demonstrating and discussing newer pressure-reduction products available to assist with wound healing and •discussing clinical indications


Question 14If clinical staff answered “True” to this question they may need further education and information about why pressure ulcers occur. Consider offering training on:• Non-compliancewithpressureulcerplanofcare• Diseaseprogression• Poornutritionalintake• OtherpressureulcerriskfactorsFor non-clinical staff additional information may include:• Trainingontheetiologyofpressureulcerformation• Reviewingtheroleofnon-clinicalstaffinpressureulcerpreventionandtreatment• Reviewingriskfactors• Informationontheirspecificroleinthecareprocessasitrelatestopressureulcers.

Question 15If staff answered “True” to this statement, it indicates they understand the emotional impact a physical condition can have on residents’ self-esteem. Pressure ulcers may limit the independence of the resident. They may also contribute to a resident feeling ‘sick’ and dependent on others for care. Additionally, many pressure ulcers occur in areas of the body that are emotionally uncomfortable for people to deal with, such as the buttocks. Dignity may be compromised if the resident feels embarrassed or ashamed over having a pressure ulcer. Family members may be angry at the facility or the resident. This could add to feelings of inadequacy the resident may already be experiencing.If anybody answered “False,” offer education to all staff, families and volunteers about pressure ulcers effect on residents’ psychosocial well-being as well as their physical discomfort.

Question 16Pressure ulcers may occur on any part of the body exposed to unrelieved pressure that decreased the flow of blood a sufficient length of time to cause underlying tissue damage. A “False” answer to this question may indicate that your staff does not understand the etiology of a pressure ulcer. Although pressure ulcers generally are noted over boney prominences of the body, they can occur at any location where unrelieved pressure is noted. Educational intervention may include:

Pressure ulcer definition and staging guidelines•Proper positioning and repositioning techniques•Proper use of pressure reduction devices•Frequent reinforcement that pressure ulcer prevention and treatment is everybody’s responsibility •

MO-08-15-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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.



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