Transcript Communicating: Old Topic, Ongoing Issues

Joyce Black, PhD, RN
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Expresses ideas
and facts clearly
◦ Legible
◦ Spelled correctly
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Provides a record
for later reference
Provides evidence
of care provided
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Date of occurrence
Events and diseases preceding ulcer
development
◦ Often assume wound is from one etiology when the
true story is not known, or not carried forward
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Past care rendered and outcomes (trajectory)
Current size, stage, other variables
Expected outcomes from patient’s
perspective
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Decubitus ulcer
on buttocks
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67 year old female who developed a sacral
pressure ulcer following surgery 7 days ago
Ulcer found 2 days after surgery, it was a deep
tissue injury
Placed her on low air loss bed for past 5 days and
limited supine position
Has a Foley in place, oral nutrition is OK
Currently ulcer is 5 x 6 x ?, it is unstageable:
fully eschar covered
Just started debridement today, had been
treating it with foam dressings and skin barrier
before
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Standard data set components inconsistent
from site to site
Standard transfer form inadequate
In the interim, ask
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Stage, size, other attributes
Date of onset, events leading to ulcer
Initial care and outcome
Current care and plan for future
Patient and family aware
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Current problems
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Ulcers “not discovered” until stage II or beyond
Staging errors
Wounds that are not pressure ulcers are staged
Frequency of assessment not consistent
Analysis of findings not apparent
 Deterioration of ulcer not addressed
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Ulcers not discovered until stage II or beyond
Plan of correction
◦ Teach aides to report any skin issues that are not
normal
 Over-reporting should be appreciated
◦ Teach aides to examine high risk areas
 Heels by looking at the heel
 Sacrum by separating buttocks folds
◦ Expect full skin assessment by licensed nurses
 Provide a documentation system to capture the
assessment and the findings
 “No new skin problems” always invites concern when
ulcers are known to be present
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Teach staging with photos
Validate it in real patients
Monitor accuracy
Once full thickness, the ulcer is
“a healing stage III/IV”
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Stage II pressure ulcers are fairly rare
◦ Skin lesions incorrectly classified as stage II’s often
include
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Incontinence associated dermatitis
Skin tears
Intertriginous dermatitis
Dehisced incisions
Important to clarify in training
◦ Pressure ulcers in areas subject to pressure
◦ Wet and dry skin more prone to ulcerate
◦ Pressure ulcers should heal if etiology corrected an
healing supported
 Other skin lesions heal on different trajectory
◦ Pressure ulcers are a quality issue, other conditions are
not always monitored in same manner
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Weekly assessment of skin in low and
moderate risk residents OK in most cases
◦ As long as risk assessment is accurate
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Daily assessment of skin in high risk
residents needed
◦ Examine skin as resident is turned or cleaned
◦ Do not position back on the red area
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Assessment of ulcer
◦ With each dressing change
 If healing, note wound is unchanged or stable
 If no change for 2 weeks, reevaluate
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Ulcers should heal
◦ That is, size decreases, necrotic tissue is less,
slough decreases or is absent, granulation tissue
appears and is pink
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When ulcer is not healing,
◦ Do not continue present treatments (they aren’t
working)
 Document review of offloading (turning, surface),
nutrition (diet and intake, weight change), topical
treatments (dressing type, change frequency, etc)
 Document plan to change, notification of family,
preference of resident for treatment, contact with MD
or WOCN
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