Transcript Wound Treatment in Long Term Care

Wound Treatment in Long Term
Care
Deborah Caswell, R.N., M.S.N., N.P.-C
Clinical Director
University Vascular Associates
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
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
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
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
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
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
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
Wound Treatment in
Long Term Care
 CMS recommends with each dressing
change:
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Assess location and staging
Size
Exudate
Pain
Color and type of wound bed tissue
Description of wound edges and surrounding
tissues
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
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
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
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
Wound Treatment in
Long Term Care
 Identify the wound type:
– Correct identification of the wound guides care
– When in doubt document what is observed
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