Wound Treatment in Long Term Care

1. Wound Treatment in Long Term Care Deborah Caswell, R.N., M.S.N., N.P.-C Clinical Director University Vascular Associates

2. Wound Treatment in Long Term Care • Wound assessment and documentation is primarily subjective, visual pen and paper exercise • Requires good base of knowledge to perform accurately • Complexity of wound assessment can lead to inconsistent documentation

3. Wound Treatment in Long Term Care • Factors that complicate wound assessment and documentation: • Different levels of knowledge among caregivers • Multiple area of documentation for wound issues is MR • Multiple wounds on one patient

4. Wound Treatment in Long Term Care • Purpose of Medical Record • Acts as a tool for communication between caregivers to aid in coordination of care • History record to determine the efficacy of past interventions and to guide future care • Evidence of quality of care used in legal action when medical errors, physical damages, etc are alleged

5. Wound Treatment in Long Term Care • Admission assessment: Good medical record documentation begins at time of admission • Snapshot of patients status…document as much information as possible • Size location and characteristics of pre existing wounds need careful documented • Absence of wounds should be documented • Document any variation from the norm

6. Wound Treatment in Long Term Care • Risk Assessment: • Should be done at admission • Information can guide comprehensive care • CMS recommends risk assessment: • on admission, • weekly for the first 4 weeks after admission for residents at risk • Quarterly or whenever a change in cognition or functional ability develops

7. Wound Treatment in Long Term Care • Risk Assessment: Validated risk assessment tools are powerful and accurate predictors of pressure ulcer development but they are useless if no one acts on the information they provide

8. Wound Treatment in Long Term Care • CMS recommendations: • Assess and document pressure ulcers with each dressing change • Monitor the dressing daily even when it is not changes • Weekly systematic assessment which allows for identifying subtle changes

9. Wound Treatment in Long Term Care • CMS recommends with each dressing change: • Assess location and staging • Size • Exudate • Pain • Color and type of wound bed tissue • Description of wound edges and surrounding tissues

10. Wound Treatment in Long Term Care • Regular monitoring and documentation of dressing status: • helps the provider determine the effectiveness of treatment and • ensures that the dressing is in place and • that it is appropriate for the wound

11. Wound Treatment in Long Term Care • Wound assessments should be concise and consistent • Plan of care should consider the factors contributing to the wound and set reasonable goals

12. Wound Treatment in Long Term Care • Tag F-314 guidelines CMS recognizes that pressure ulcers are unavoidable if staff documented that they took the following measures: • Evaluated the residents clinical condition and pressure ulcer risk factors • Defined and implemented interventions consistent with the resident’s needs, goals, and recognized standards of practice • Monitored and evaluated the impact of the interventions • Revised the approaches as appropriate

13. Wound Treatment in Long Term Care • Response to discovering a pressure ulcer: • Document who was notified • Note any topical care that was provided, creams, ointments, dressings, etc • Describe actions taken to minimize further damage

14. Wound Treatment in Long Term Care • Identify the wound type: • Correct identification of the wound guides care • When in doubt document what is observed

15. Wound Treatment in Long Term Care • Wound photography: • Series of images allows for more efficient and informed interventions • Wound imaging supplements but does not replace need for written documentation • Would support facilities quality, consistency, and documentation of care for the wound