Wound Care in LTC facilities

L. Gurvich APN, M.S., MPH, CWS.L. Gurvich APN, M.S., MPH, CWS.

Chicago 2009

Purpose

Wound Care expertise (CWS) “Bringing” Wound Center to NH Emphasizing prevention as a core value Emphasizing prevention as a core value Instant staff in-service and education

Program Benefits

Higher RUG score for MDS Longer LOS for Medicare patients Constant supervision of patient care Constant supervision of patient care Goal is “0 tags“ on PH inspections

Program Benefits

Defensive documentation against “tags” Reduction in risk of lawsuits Avoiding hospital visits and admissions Avoiding hospital visits and admissions Cost

How it works?

Weekly rounds with wound team E&M wounds of all etiology, abscess.. Bed side sharp clinical debridements Bed side sharp clinical debridements Prescribing treatment orders, care plan F/U visits, on-call 24/06

How it works?

Goal: Restoring natural path of healing Treating the cause of problem: Vascular assessment: Doppler,… Vascular assessment: Doppler,… Pressure Offloading: surfaces, pillows…

Wound care is not just skin care

Nutrition: Alb,(prealb) Vit’s, G-Tube Infection: tissue C/S, Antibiotics

systemic and topicalsystemic and topical Multidiscipline : PT, OT, Dietary, PCP,

CNA’s

Before we start

Care based on written order from PCP Order should be placed in patient chart. Informed consent for wound Informed consent for wound

evaluation, debridement andphotography signed by patient or POA.

For first time telephone consent is O.K

Expectations:

Carrying out treatment orders Following the treatment plan Report about any significant change in Report about any significant change in

Pt condition or treatment plan Update PCP and families about progress

Treatment cart

Container for sharps instruments Disposable tray for each Pt

Treatment tray

Biohazard Red bag

Documentation

Printed consultation notes after eachvisit.

Notes placed in Pt’s chart Notes placed in Pt’s chart Notes as a source for care plan Narrative notes reflecting wound care

progress / specialist site visits

Debridement

before after

Debridement

before after

Debridement

•

after

Debridement of R Hip decubitus ulcer

Current healing state

Frost bite

Frost bite healing state

Self-trauma / Burn

12-2007

Healed

Healed 11 months later

4 weeks

Heel Decubitus ulcer. 89 Y Female, Dementia, Contractures

11-20074 weeks

12 months Healed 15 months later

Diabetic foot with Osteomyelitis

12-2008 Healed 3 month later

Bilateral Ischium stage IV ulcers

1-16-091-16-09

Healed 9 month later

Documentation

Aq/Admit Date

TunnelingColor

IV Pressure/ Vascul/Skin alterUlcers Location SacralStage/ Type

Size LxWxD in CmUndermining 2cm at 12 o'clock

4 cm at 6 o'clockP/R/B/Y/Br

Exudate Amount modExudate Type serGranulation Amount/Type ##Necrosis/Eschhar Am #Slough/Fibrin Amount #

ErythemaOdor

Dressing Instruction Dressing InstructionFrequency QD And PRNClean with

Cover withAnchorage and

Slough/Fibrin Amount #Periwound Mac/ Red/Indurated

Signs of Infection minimalExposed Tend/Mus/Bone BTM

2cmMin/ Foul/Necrotic

Changes since last visitImproved/Worsed/Unchanged

Topical ApplicationN.Saline/WCleanser

ACE band/ Take off HS

Santyl + Adaptic4x4

Date

Braden Scale

SensoryPerception 2 Bed Moisture(

1

Walking Activity 1 Bed Mobility 3

Nutrition 3 Friction and Shear 2

Risk factors contributing to wound healing

Braden Scale < 18 x

Age 65 or older x Dementia Malnutrition Vasculitis

Agitation Def- Feet Medications xVenousStas

Anemia Diarrhea MSUnderweightAnemia Diarrhea MS t

Arthritis Edema Multi S. DisWeightLoss

CAD Frail PVD

Cancer & Chemother Fracture/Cast Obese Others

Chewing difficulties x Hemodialysis Pain xNo improved for 2-4weeks

Confusion Hospice Parkinson

COPD/Resp Fal Immun-suppr Renal Insuf

Contractures Steroids Sepsis

CVA A.Immune Dis Skin Path

Dysphagia Immobility

Diabetes Incont Urine SCI x

Dehydration Incont Fecal Spasticity

Depression Liver Dis Tobacco Use

Preventive Measures Recommended or Already inplace

Daily Skin Check Foam Wedge/ Positioning Pillows

Sitting in w/c only for meal time x Restorative Program x

2 hrs Turning schedule G Tube

Stage Appropriate Mattress Foley

Heel Protectors x Colostomy x

W/Ch Cushion Texas Cath

Conclusion

• Comprehensive wound care program• High healing rate• In-service, staff education• High cost- effectiveness• High cost- effectiveness

After conclusion

Treat a whole patient and

notnot

a hole in the patient

About the Author

• Leon Gurvich: is an Adult Nurse Practitioner• Master of Public Health ( MPH)• Board certified Wound Specialist (CWS )• 15 years of Nursing experience• 15 years of Nursing experience• 10 years of Wound care practice

Publications and research

• Poster Presentations in Symposium on AdvancedWound Care in 2006, 2007, 2009 with main topics: Limbpreserving, Maggots treatment, Growth factors therapy

• Publications : Article “Double impact”: Synergism in• Publications : Article “Double impact”: Synergism inusing Negative Pressure Wound Therapy with alternatedapplications of Autologous Platelet-Derived GrowthFactors in treating post acute surgical wounds. Caseseries.” “WOUNDS” Journal, May 2009.

Appendix: supply recommendations:

Nursing home in house stock: Hydrogel ( SAF Gel or Integrity)

Non adhesive :Adaptic Non adhesive :Adaptic ACE bandage 4 and 6 inch Tubigrip sizes: D, E, F Collagens/ Alginates

Appendix: supply recommendations

Collagens: Fibracol,Prizma, Promogran,Puracol

Alginates: Aquacel,Ag, Maxsorb None adhesive: Adaptic, Aquaphore Ointments & Creams:Hydogel, Baza, A+D SkinLotion: Ammonium Lactate12%, Eucerin, Enzymatic: Santyl, Xenaderm

Appendix: supply recommendations

Compression: Profore and Profore Lite, Unnaboot, ACE bandage 4’’ and 6”, Tubigrip orMedigrip sized C, D, EAntiseptic solution: Iodine solution, Dakin’s Antiseptic solution: Iodine solution, Dakin’s½ str solution

Silver based products: Silvadene cream,Silvasorb gel, Acticoat absorbent and Acticoat -7

Antimicrobial: Iodoflex, Iodosorb, Bactroban,Triple antibiotics, Bacitratcin . Iodoform Tape.