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:– 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