Resource Guide: Pressure Ulcer Prevention and ... - HealthInsight

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IDENTIFICATION AND TRACKING OF PRESSURE ULCERS In February 2007, The National Pressure Ulcer Advisory Pane (NPUAP) redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages (Stages 1 – 4) and adding 2 stages on deep tissue injury and unstageable pressure ulcers. The staging system provides a name to extent of tissue damage. Only those wounds that are caused by pressure should be staged. Resources and tools for identifying and tracking pressure ulcers: • Pressure ulcer staging definitions (NPUAP): National Pressure Ulcer Advisory Panel (NPUAP) • Photos: • Stage 1 (NPUAP) • Stage 2 (NPUAP) • Stage 3 (NPUAP) • Stage 4 (NPUAP) • Unstageable (NPUAP) • Suspected Deep Tissue Injury (NPUAP) • Quick Assessment of Leg Ulcers (WOCN) • Pressure Ulcer Admitted vs. Acquired Tracking Tool (Advancing Excellence in America’s Nursing Home Campaign) 10
ASSESSMENT AND DOCUMENTATION OF PRESSURE ULCERS With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed and: • Location and staging; • Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; • Exudate, if present: type (such as purulent/serous), color, odor and approximate amount; • Pain, if present: nature and frequency (e.g., whether episodic or continuous); • Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and • Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate. The CMS Manual System Guidance to Surveyors for Long Term Care Facilities, Appendix PP; F314 The RAI User’s Manual should be used to assist in the coding of skin conditions on Section M of the MDS. It is important to note some key changes in coding section M from MDS 2.0 and MDS 3.0. On MDS 3.0: • Nursing homes not only have to indicate the number of pressure ulcers at each stage, but they have to record the number of arterial and venous ulcers as well as the most severe tissue type for any pressure ulcer. • Facilities must also record how many stage 2–4 pressure ulcers were present on admission. There are very specific rules for how to record the stages of pressure ulcers that were present on admission. These rules can be found on page M-6 of the RAI User’s Manual. • Report based on the highest stage of the existing ulcer at its worst, rather than use the reverse staging method of the MDS 2.0. • It is required that facilities record the length, width, and depth of the largest stage 3 or 4 pressure ulcer a resident has. • Facilities are required to record the number of stage 2, 3, and 4 pressure ulcers that were not present or were at a lesser stage on a prior assessment. 11
Page 1 and 2: Updated November 2011 Resource Guid
Page 3 and 4: PURPOSE This guide is intended to a
Page 5 and 6: • One in five nursing home reside
Page 7 and 8: Non-Blancheable-Reddened areas of t
Page 9: • Pressure Ulcer Prevention Quick
Page 13 and 14: PRESSURE ULCER TREATMENT STRATEGIES
Page 15: ADDITIONAL RESOURCES • Agency for

Resource Guide: Pressure Ulcer Prevention and ... - HealthInsight

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