Wound care is one of the most difficult duties for long-term care providers. Often, they must deal with wounds that did not originate on their watch (i.e., hospital-acquired). Furthermore, totally avoiding later stage wounds is not always possible. This piece offers expert advice on how to navigate wound care matters to avoid further problems with resident care, and regulators.
1
Wound care professionals must start on the right foot, so to speak.
“The initial resident assessment must include not only an accurate skin assessment but also a description of existing wounds or pressure ulcers or areas of the skin that may indicate tissue or skin damage,” says Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, Vice President for Clinical Services at RecoverCare.
“Something as innocent-appearing as a reddened area or a blister on the skin could actually be deeper tissue damage that will results in a diagnosis pressure ulcer if the site is located over a bony prominence.”
2
Although the MDS 2.0 does not provide the clinician with a place to note a stage or grade for these particular areas, the National Pressure Ulcer Advisory Panel (NPUAP) has defined categories that describe these skin conditions with specific stages. The group has updated the definitions recently in response to requests from professionals.
NPUAP includes photos on its website for educational purposes. They can be viewed at www.npuap.org and downloaded.
3
Even though some professionals have advised that while the tissue in these areas cannot be accurately staged in documentation on the MDS 2.0 form, long-term care facilities should identify and document a complete description in the nurses note section of the resident record, Jordan says.
“These are areas that may be described as either an unstageable pressure ulcer or an area of ‘suspected deep tissue injury,’” she explains. “An unstageable pressure ulcer is tissue where the wound bed cannot be visualized.
The wound bed is obscured by dead tissue and identified as slough or eschar. Upon debridement, the area previously covered with the non-viable tissue will often be staged as a stage III or stage IV pressure ulcer.”
4
Documenting a wound’s progression each step of the way is vital. Trying to recreate the record after the fact is asking for trouble.
“If the initial observation is not documented until the wound bed is visible, this could result in a mistaken assertion that the pressure ulcer was an ‘in house’-developed pressure ulcer,” Jordan notes.
“Another frequent dilemma is an area of tissue over a bony prominence that appears as a bruise or blister filled with fluid. This may actually be an area that should be suspected as a pressure ulcer with an unknown depth and therefore be characterized as ‘unstageable.’ If there is a purplish color or the fluid in the blister appears as blood or dark colored fluid, this would be an area of suspected ‘deep tissue injury.’ These areas are often not identified, and result in little or no documentation and no documented plan of care. The results can result in citations as “in facility”-acquired pressure ulcers.”
5
Experts remind that there is no pressure ulcer that doesn’t require intervention of some sort. And remember: Any intervention must be noted in the care plan and recorded in nursing and therapy notes.
At a minimum, they should include frequent risk assessment, skin and ulcer assessment, nutritional and hydration assessment and intervention, along with turning and repositioning and support surfaces, Jordan says.
“If all care is instituted and followed along with appropriate documentation and change in care as the resident’s condition requires,” she explains. “Most pressure ulcers are arguably ‘non-avoidable’ pressure ulcers and will provide the grounds for the facility to avoid citations of late-stage pressure ulcer development while the resident resides in the facility.”
6
Some experts caution against being overly reliant on the promise of modern technology. Basic preparation for healing is paramount.
From the June 01, 2010 Issue of McKnight's Long-Term Care News
