When it comes to wound care in long-term care, pressure ulcers often receive the highest priority from skilled nursing staff and administrators – often for good reason.
“Pressure ulcers have significant potential for both morbidity and mortality, as well as being a high risk for litigation,” says Japa Volchok, DO, Vice President of Operations at Vohra Wound Physicians.
But what about the challenges of treating non-pressure wounds such as arterial, venous and diabetic ulcers, skin tears or abrasions, puncture wounds and scrapes?
These types of conditions account for about 60% of wounds in long-term care, and they can have a significant impact on residents’ quality of life, says Mark Ross Hopkins, LVN, WCC, Wound and Product Specialist at Gentell.
“Pressure ulcers may be the ‘star of the show’ in long-term care, but arterial and venous ulcers, skin tears and abrasions and diabetic ulcers are certainly ‘best supporting actors,’” Hopkins says. “If they’re not diagnosed properly, they can be very debilitating to a resident.”
Thorough skin assessments, precise documentation, ongoing staff education, the right equipment and a positive relationship with local acute-care facilities can all help in a facility’s ability to provide excellent wound care for its residents, experts say.
“To help ensure all wounds receive the care and attention they deserve, facilities need innovative and effective ways to care for today’s complex skilled nursing patient,” says Dawn Fortna, MSEd, CDE, CWOCN, Clinical Nurse Educator with Medline.
Why so much pressure?
Pressure ulcers have been given a magnitude of attention in long-term care over the last decade, having been the focus of regulatory, education and dressing innovation efforts, while non-pressure wounds have not received the same amount of attention. For example, facilities must report worsening pressure ulcers in their facilities though the Minimum Data Set (MDS), as well as other mitigating factors that aggravate pressure ulcers, such as urinary incontinence and mobility.
“Non-pressure wounds are less understood across all levels of long-term care and often receive less concern and inquiries from families,” says Volchok, who is also a vascular surgeon.
Fortna agrees, noting that many resources from a facility’s already shrinking budget go toward implementing protocols and education for pressure injuries.
Non-pressure wounds, however, are often more complex and require higher levels of training and skill to properly diagnose and treat — a challenge for time-strapped long-term care nurses who have to be knowledgeable in multiple areas of care, Fortna says.
“Wound care is a specialty of its own and there is a lot to learn,” she says. “Education and evaluation needs to be ongoing as best practice continues to evolve.”
In addition, the MDS often requires wounds to be miscategorized for its purpose, leading to clinical confusion about just what etiology the wound is and how it should be treated, says Dea J. Kent, DNP, RN, NP-C, CWOCN, president-elect of the Wound, Ostomy and Continence Nurses (WOCN) Society.
“Because documentation supports the MDS, nurses must chart to support the MDS category, which is problematic because everything is a pressure ulcer and not all wounds on the leg are vascular in nature,” she says.
Patients take their cue from the nursing staff, and if the nursing staff is confused due to the convolution of the information, then the patients ultimately will be confused as well.
Another reason non-pressure wounds may not always be managed as carefully as they should be is because they require special expertise to manage well, and can require a multidisciplinary approach involving physicians from multiple specialties, says Volchok.
Take, for example, venous ulcers, which account for about 6% of wounds in long-term care. Proper treatment for venous ulcers often calls for bandages that provide gentle compression of the leg.
An improper diagnosis, examination or application of a compression dressing can have drastic consequences and can result in the loss of a limb.
“Having a physician available who can properly diagnose a venous ulcer, examine and confirm adequate arterial blood flow, and then having a nurse trained in the application of compression dressings can pose a challenge for long-term care facilities,” Volchok observes.
Improved clinical outcomes start with knowledge and education and it is important that these exist at all levels from physician staff to nurse assistants.
“When knowledge is lacking, the prevention, diagnosis and proper treatment of these types of wounds will suffer,” he says.
Ensuring proper assessment
In an effort to thwart any type of skin wound before it becomes a problem, clinicians need to complete a thorough skin assessment daily during patient rounds, says Amy Grey, clinical leader of wound care for Essity.
“Precise documentation of a wound is imperative to monitoring changes and adapting treatments,” she says.
Once a wound is discovered, facilities should perform diagnostic studies to determine the root cause, as this is critical to a resident’s treatment plan, says Hopkins.
“Oftentimes, wounds to the lower extremities are diagnosed as pressure wounds but are found not to be after diagnostic studies and clinical review,” he says. “Identifying the root cause allows for successful treatment and also affects quality measures, pressure rating percentage and overall patient and family satisfaction with the long-term care facility.”
Equipment also can play a big part in skin integrity issues, says Kelly Sullivan, Senior Product Consultant of Rehabilitation for Direct Supply.
“Imagine sitting on a vinyl sling seat of a wheelchair without a cushion,” she says. “The hammock effect would lead to adduction, forcing your legs to slide against each other and causing friction between the knee joints. Continuous pressure against your hips from the frame and sling seat could lead to bruising or skin tears.”
To avoid this, she recommends adding a cushion with a rounded bottom to residents’ wheelchair seats, as a way to help fill in the sling gap and offload pressure from the ischial tuberosity and coccyx region.
Proper treatment depends on the wound type itself, Hopkins notes.
Some of the most common wounds seen in long-term care are skin tears and abrasions, as thinning of the skin is an unfortunate side effect of advanced age and certain medications. Most of the time, skin tears are of surface depth, but the risk of infection is still present, he says.
“Each nurse has his or her own method for healing a skin tear, but the most important factor is infection control and reducing contributing risk factors,” he says. “Once a skin tear has been discovered, cleansing the wound properly is essential.” He also recommends that facilities take a proactive approach to preventing skin tears — and that doesn’t have to mean spending a significant amount of money on prevention sleeves.
“Often a simple long-sleeved shirt will suffice,” he says.
When it comes to treating diabetic ulcers, patient education and management of the resident’s fasting blood glucose levels takes center stage, Hopkins says.
Wound healing slows when glucose levels are consistently elevated.
Therefore, staff and residents must be taught about how glucose levels affect healing.
“Like treatment and plans of care for pressure ulcers, care of non-pressure wounds should be individualized,” Hopkins says. “As the long-term care setting presents a plethora of opportunities for a wound nurse, it also presents a lifetime of learning opportunities.”
Special oversight needed
Speaking of a lifetime of learning, when it comes to wound care, long-term care staff simply need more training, experts say.
“Basic skin care and knowledge of the importance of skin breakdown prevention is a key component to improved outcomes, and caregivers need to understand that any break in the skin may allow bacterial entrance and lead to septicemia and a potentially fatal situation,” Fortna says.
Kent agrees, noting that education for staff — from CNAs to nurses to dieticians — on the basics of pressure and non-pressure wound and skin injury prevention must be provided.
“Everyone in the facility is a caregiver, and everyone can help with the prevention effort,” she says.
Long-term care nurses should also be training in wound etiology and treatment, accurate wound assessment and how to relay reports and ask questions when a good report isn’t given, she adds. Designating one or two nurses specifically as “wound care nurses” and sending them for education through, for example, the Wound Treatment Associate program through the WOCN Society is also ideal, Kent says.
Finally, she says, don’t take an “us versus them” attitude when it comes to wound care.
“Neither acute-care nor long-term care facilities want to be ‘at fault’ for the development or worsening of any type of wounds,” she says.
Instead, Kent recommends that directors of nursing and skilled nursing administrators make a point to initiate and cultivate relationships with acute-care facilities, wound experts and wound care clinics in their community and encourage mentorship for their nurses from these experts.
“These are the aspects of care that require thoughtful attention and action, but it can do wonders for the sake of the patient,” she says.