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Improving Quality of Care Based on CMS Guidelines

Volume 4, Issue 2

Top Issues
Affecting Your
Take the survey today!

How to bear
What does it
mean to you?

cancer FREE PAGE
CE! 18
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Improving Quality of Care Based on CMS Guidelines

Sue MacInnes, RD, LD Contents
Clinical Editor Survey Readiness
Margaret Falconio-West, RN, APN/CNS, 20 Untangling the Terms
ET, CWOCN, DAPWCA 48 Wound Care Competency Day
60 Love Them Two Times
Clinical Team
Cynthia A. Fleck, RN, ET/WOCN, Treatment
CWS, DAPWCA, MBA, FCCWS 12 Understanding Skin Tears
Janet L. Jones, RN, PHN, ET, CWOCN, 22 What’s That Noise?
DAPWCA 34 Seat Cushions Page 23
Joyce Norman, RN, CWOCN, DAPWCA 40 Taking the Fear out of Male Catheterization
Elizabeth O’Connell-Gifford, RN, 45 If the Shoe Fits…
CWOCN, DAPWCA, MBA 53 Perineal Skin Care for the Incontinent Resident
54 Case Study: Using Olivamine in a Skin Cream to Improve
Carol Paustian, RN, ET, CWOCN,
Skin Quality in Diabetic Patients
56 Easing the Pain
Amin Setoodeh, RN
Deb Tenge, RNC, MS, CWOCN, Special Features
Licensed Administrator 5 Top 10 Issues Affecting Your Clinical Practice Today Survey
Jeannine Thompson, RN, CWOCN 6 Two Important National Initiatives for Improving Quality of Care Page 34
Jackie Young, RN, ET, CWCN, DAPWCA 11 Advancing Excellence Campaign Goals
26 The Perils of Ineffective Handwashing
Wound Care Advisory Board 31 The Key to Hand Hygiene
Mona Baharestani, PhD, ANP, CWOCN, 38 Incontinence
FCCWS, FAPWCA 64 Anurse in WOUNDerland
Ann Blackett, MS, RN, COCN, CWCN, 74 Sharpening the Saw
Patricia Coutts, RN Forms & Tools
88 Guidelines for Wound Photography
Pat Emmons, RN, MSN, CNS, CWOCN
89 Prevention of Skin Tears – In-Service Outline Page 60
Cindy Felty, RN, CNP, MSN, CWS, FCCWS 90 Bates-Jensen Wound Assessment Tool
Lynne Grant, CNS, MS, RN, CWOCN 92 PUSH Tool 3.0
Teresa Kellerman, MSN, ARNP, WOC/CNS 94 Quick Guide to Lab Values
Bette Kussmann, RN, CWCN, COCN
95 Foley Catheter Selection Guide
Andrea McIntosh, RN, BSN, CWOCN, APN Regular Features
Cathy Milne, MSN, APRN, CS, CWOCN, ANP 4 Letter from the Editor
Laurie Sparks, RN, ET 8 News Flash
Shelia Thomas, RN, CWOCN 16 CE-Credit Crossword Puzzle: Understanding Skin Tears
51 Hotline Hot Topic Page 78
58 Product Spotlight: Silicones
Lynne Whitney-Caglia, RN, MSN, CNS, CWOCN
Laurel Wiersema-Bryant, RN, BC, ANP Caring for Yourself
Linda Woodward, RN, OCN, CWOCN 70 Respect
78 “Dr. Marla” Battles Breast Cancer
© 2007 Medline Industries, Inc. Healthy Skin
84 Best Day/Worst Day is published by Medline Industries, Inc.
86 Recipe: Berries & Cream Pound Cake One Medline Place, Mundelein, IL 60060
1-800-MEDLINE (633-5463)

Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals,
extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than
700 dedicated sales representatives nationwide to support its broad product line and cost management services.
For more information on Medline, visit our Web site,

Improving Quality of Care Based on CMS Guidelines 3

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HEALTHY SKIN I Letter from the Editor


Recently, CMS released the final PPS rule for If you would, please take a moment to
hospitals. This is a significant policy change complete the survey on the following page
that will ultimately improve the quality of and tell us your biggest challenges. We
care by no longer paying for preventable want to direct future content to address your
conditions that are acquired in hospitals. pressing concerns by first sharing the results
These conditions include pressure sores, in our next issue and then by tailoring future
UTIs and falls. articles to give you those practical solutions
that target your needs.
What do you think will happen next? It’s
only a matter of time before reimbursement We know that your concerns on the job
for LTC and home health are also centered also include daily interactions with peers
around patient outcomes and more cost- and motivating your staff. To that end,
effective healthcare by putting the focus on we’ve included an article titled “Respect” to
prevention. Patient hand-off between health- remind us of how important it is to manage
care providers will be a major focus in the the interaction between our co-workers and We all can agree
future. To that end, we intend to continue professionals from other healthcare entities. that we should do
to bring you industry news and examples thing right ... but
of successful collaborations. We invite you Finally, we are thrilled to feature an article it is our goal to
to share your experiences – both good by Dr. Marla Shapiro, the well-known make it hard for
and bad – so that others can learn and Canadian physician, columnist, TV personality the healthcare
benefit. Please feel free to contact me at and breast cancer survivor, to inspire us all worker to do with anything to remember the importance of our families things wrong.
you would like to share. and friends. Her story is touching and her
message a wake-up call to take care of
Once again included in this edition are the ourselves and to balance our lives between
key initiatives in home health and long-term our work, family and self.
care (see Page 6). Notice the icons at the
bottom of this page. You will see these icons Best regards,
throughout the magazine whenever an
article supports one of these quality goals.
Then, on Page 11, follow the crosswalk of Sue MacInnes, RD, LD
national initiatives. The Web site addresses
of these organizations are provided so that
you can explore the resources available to
assist you in your practice.

Content Key
We’ve coded the articles and information in this magazine to indicate which National Quality
initiatives they pertain to. Throughout the publication, when you see these icons you’ll know
immediately that the subject matter on that page relates to one or more of the following
national initiatives:
• QIO – Utilization and Quality Control Peer Review Organization
• Advancing Excellence in America’s Nursing Homes

We’ve tried to include content that clarifies the initiatives or give you ideas and tools for imple-
menting their recommendations. For a summary of each of the above initiatives, see Page 6.

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We want to hear from you!

Healthy Skin wants to hear

what you, our readers, think
are the top 10 most important
issues in your practice today!
And for your time and effort,
we will send you an Angel
nurse doll. Go to
Affecting Your Clinical
Practice Today to complete the survey.

1Simply go to the Internet and type in

2 Click on Top 10 Issues Survey.
3 Rank your top 10 issues and concerns from one to 10.
Issues affecting your practice: Additional issues:
Survey Process
Wound Care Product Selection
Aging Facilities
Liability Claims
When you have completed the survey, just click enter
Staffing and your answers will be submitted for calculation.
Resident and Family Satisfaction Deadline for submission is October 31, 2007. Check
out the results in the next issue of Healthy Skin.
Staff Development
Supply Management Please select one that best describes
your area of practice:
Fall Prevention
Safety/Risk Home Health
Nursing Home
Infection Prevention
Wound Clinic
Cost Control
Pressure Ulcer Prevention
Patient Handoff
Pain Management

To take the survey and receive

your Angel doll, go to
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Two Important National Initiatives

for Improving Quality of Care
Achieving better outcomes starts with an understanding of current quality
of care initiatives. Here’s what you need to know about national projects and
policies that are driving changes in nursing home and home health care.


Origin: The QIO Statement of Work (SOW) is based on Part B of Title XI of the Social Security Act. The QIO is currently
operating within its 8th Round SOW contract cycle, which started in August 2005 and will be in effect
until July 2008.
Purpose: In the 8th Round SOW, QIOs are expected to provide assistance to providers that enable them to develop the
capacity for and to achieve the vision that every person receives the right care every time.
Goal: CMS has identified a set of Breakthrough Priorities for improvement. The purpose of these Breakthrough Priorities
is partly to improve care, but more importantly to transform the expectations of participants in improvement by
making very substantial improvement a fully credible ambition.

Quality Improvement Organization (QIO) Program’s 9th Scope of Work

The Centers for Medicare and Medicaid Services’ Office of Clinical Standards will be seeking comments beginning
September 2007 on the Quality Improvement Organization (QIO) Program’s proposed 9th Scope of Work. The 9th Scope,
which begins on August 1, 2008, will run through July 31, 2011.

Information about the 8th Scope of Work is provided at



Origin: A new coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing
home residents and staff.
Purpose: A coalition consisting of the Centers for Medicare and Medicaid Services (CMS), organizations representing providers,
consumers and government that developed a grassroots campaign to build on and complement the work of existing
quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.
Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition
has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction
surveys into continuing quality improvements and increase staff retention to allow for better, more consistent
care for nursing home residents.

Participating providers will commit to focusing on at least three of the eight measurable goals, including at least
one clinical goal and one operational/process goal.

Advancing Excellence
The Advancing Excellence in America's Nursing Homes campaign kicked off in the fall of 2006 at a national Nursing
Home Quality Summit in Washington, D.C. 5,705 facilities nationwide have committed to work on at least three of
the campaign's goals.

To download the Advancing Excellence tool kit, go to

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Special Features

Check out the Web sites for these initiatives!

8th Statement of Work:
Advancing Excellence:
American Health Care Association:


Task 1a: Nursing Home - Task 1b: Home Health -

Clinical Performance measures Clinical Performance measures
• High-risk pressure ulcers • Improvement in bathing
• Physical restraints • Improvement in transferring
• Management of pain in chronic • Improvement in ambulation/locomotion Progress reports will be
posted on
(long-stay) residents • Improvement in management of
for both campaigns beginning
• Management of depressive symptoms oral medications September 2007
• Improvement in pain interfering
Organizational Change and Process with activity
Improvement Measures • Improvement in status of surgical wounds
• Conduct annual employee • Improvement of dyspnea
satisfaction surveys • Acute care hospitalization
• Conduct annual resident • Discharge to community
satisfaction surveys • Improvement in urinary incontinence
• Calculate annual CNA turnover rates


Clinical Goals: Operational/Process Goals:

Goal 1: Reducing high-risk pressure ulcers Goal 5: Establishing individual targets for
Goal 2: Reducing the use of daily improving quality
physical restraints Goal 6: Assessing resident and family
Goal 3: Improving pain management for satisfaction with quality of care
longer-term nursing home residents Goal 7: Increasing staff retention
Goal 4: Improving pain management for Goal 8: Improving consistent assignment of
short-stay, post-acute nursing nursing home staff so that residents
home residents receive care from the same

Trends in Goal Selection

Each nursing home participating in Advancing Excellence selects a minimum of three goals (outlined
above). The goals – and the percentage of participating nursing homes that have selected them –
are listed below.

Goal 1: 68.6% Goal 5: 29.7%

As of September 1, goals 1,
Goal 2: 42.4% Goal 6: 65.2% 3 and 6 have the highest
Goal 3: 53.6% Goal 7: 39.6% participation rates.
Goal 4: 39.7% Goal 8: 33.5%

Stay tuned! First year results will be published in the January 2008 issue of Healthy Skin!

Improving Quality of Care Based on CMS Guidelines 7

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CMS Releases Inpatient PPS Final Rule for 2008

Will this impact resident-centered care?
On August 1, 2007, the Centers for Medicare & Medicaid Services (CMS) released the inpatient prospective payment system
(PPS) final rule for fiscal year (FY) 2008. The policies and payment rates included in this rule become effective October 1, 2007.

The rule adopts eight conditions, including three serious preventable events, for which CMS will not provide higher payments if
the selected event occurs while a patient is under the care of the hospital. The changes will take effect for FY 2009 and will
• Object left in surgery • Pressure ulcers
• Air embolism • Vascular catheter-associated infections
• Blood incompatibility • Mediastinitis after coronary artery bypass graft
• Catheter-associated urinary tract infections • Falls

CMS will continue its three-year transition to cost-based relative weights, with two-thirds of the
FY 2008 weight based on costs and one-third based on charges.

Consider your resident population and the continuum of care with regard to transfers both to and
from acute-care settings. A display copy of the document is available at

CMS Issues Revised Guidance for F323 – Accidents & Supervision

The Centers for Medicare & Medicaid Services (CMS) has issued revised guidance for Accidents and Supervision (Tag F323) that
became effective on August 6, 2007. The revised guidance combines Tags F323 and F324 into one tag, F323.

According to the Survey & Certification Memorandum that accompanies the guidance, the interpretive guidelines clarify areas such as
resident supervision, hazard identification and resident risk, falls, unsafe wandering/elopement, environmental assessment of hazards
and resident-to-resident altercations.

For complete information, please refer to the actual guidance and training materials, available at

This section includes two behaviors for which a facility may provide supervision: Resident smoking and resident-to-resident altercations.

Hazard Identification and Resident Risk: Deficiency Categorization

Resident Vulnerabilities: Actual or potential harm/negative outcome for F323 may include,
• Falls but is not limited to:
• Unsafe wandering or elopement • Injuries sustained from falls and/or unsafe
• Physical plant hazards wandering/elopement;
• Chemicals and toxins • Resident-to-resident altercations;
• Water temperature • Thermal burns from spills/immersion of hot water/liquids;
• Electrical safety • Falls due to environmental hazards;
• Lighting • Ingestion of chemical substances; and
• Assistive devices/equipment hazards • Burns related to smoking materials.
• Assistive devices for mobility

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Update on
HAIs from CDC: Celebrating the 21st Annual
A new report from the Centers for
Disease Control and Prevention NADONA/LTC
(CDC) contains the following updated National Conference, Caesars Palace,
estimates of healthcare-associated Las Vegas, Nevada
infections (HAIs):
• An estimated 1.7 million Held June 23 to 27, 2007 this year’s conference and exposition had
more than 800 in attendance.
infections and 99,000 associated
deaths occur each year Kicking off the event was the keynote speaker, Andrea Higham,
• Equivalent to 1 death every Director of Corporate Equity and the Johnson & Johnson Campaign
6 minutes For Nursing’s Future, which highlighted “The Promise of Nursing.” This
• Annually add $5 – $6.7 billion session was not only inspirational; it also set the tone of the conference
to U.S. healthcare costs and emphasized the bright future of nursing.
• Types of infections:
Molly Morand, President of the Morand Group, LLC was once again
— 32 percent of all
on hand to deliver her presentation titled “Just Say No to Mandatory
healthcare-associated In-Services” to a packed audience.
infections are urinary
tract infections “Compassion Fatigue – Preparing Professionals to be Resilient”
— 22 percent are surgical explored the signs and coping measures for compassion fatigue and
site infections offered strategies to assist in developing resiliency. This session was
presented by Barbara Rubel, MA, BCETS, CBS, CPBC, Executive
— 15 percent are pneumonia
Director of the Griefwork Center, Inc.
(lung infections)
— 14 percent are Medline Industries, Inc. introduced their revolutionary educational
bloodstream infections packaging (EP Packaging) for advanced wound care to all DONs
Hand hygiene is one way to (Directors of Nursing) who attended this meeting.
decrease the spread of infection.
With more than 6,000 members, The National Association Directors
Learn how to make hand hygiene a
of Nursing Administration in Long-Term Care, or NADONA/LTC, is the
success in your facility by reading
largest educational organization committed exclusively to nursing and
“The Perils of Ineffective Handwashing” administration professionals in the Long-Term Care and Assisted-
and “The Key to Hand Hygiene” on Living professions.
pages 26 and 31.
Mark your calendars for June 21 to 25, 2008 when the 22nd Annual
Reference: NADONA/LTC National Conference will be held in Nashville,
The Centers for Disease Control and Tennessee at the Gaylord Opryland Hotel and Conference Center.
Prevention. Estimates of Healthcare-
Associated Infections. Available at:
Accessed August 23, 2007. attendees share their
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How 4 square inches of Puracol Plus

changed chronic wound care.

Look closely. It’s not a bandage. It’s Puracol™ Plus

MicroScaffold™, made entirely of pure native collagen.
Chronic wounds tend not to heal when unbalanced levels
of elastase and MMPs (inflammatory enzymes) destroy
the body’s own collagen and growth factors.1
But apply Puracol Plus and help restore nature’s balance.
In vitro studies show that Puracol Plus has the ability
to reduce the levels of elastase and MMPs from
This is Puracol Plus Micro- surrounding fluid.2
Scaffold as seen through an
electron microscope. Its open,
cellular structure allows easy
fibroblast migration.2 The high
strength of the MicroScaffold2
also assists in establishing a
fresh wound bed.

Each Puracol package, like

every other Medline wound care
package, is a 2-Minute Course™
in Advanced Wound Care.
1. Schultz GS, Mast BA. Molecular analysis of the environ-
ment of healing and chronic wounds: Cytokines, proteases,
and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F.
2. Data on file.
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Special Features

Advancing Excellence
Campaign Goals:
A cross-reference outlining the clinical
and performance goals included in all
four National Initiatives in long-term care.
Did you know all of the National Initiatives are closely related?
There are currently four national initiatives striving to improve the quality of
long-term care in America:
• American Health Care Association’s (AHCA) Quality First -
• Nursing Home Quality Initiative’s (NHQI) QIO Goals -
• Nursing Home Culture Change Movement -
• Advancing Excellence in America’s Nursing Homes -

To learn more about each initiative, you are invited to visit each group’s Web
site, where they offer detailed information and educational tools.

Goal Quality NHQI Culture Advancing

First QIOs Change Excellence
Pressure Ulcers X X X
Physical Restraints X X X
Chronic Pain X X X
Post Acute Pain X X X
Setting Targets X X
Customer Satisfaction X X X X
Staff Turnover X X X X
Consistent Staffing X X

Improving Quality of Care Based on CMS Guidelines 11

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Reprinted with permission from EPCN

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Improving Quality of Care Based on CMS Guidelines 13

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Improving Quality of Care Based on CMS Guidelines 15

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As the primar y supplier to more than 2,700 home health

care agencies nationwide, we know what you require
from a strong business partner. That is why Medline
HomeCare provides innovative solutions for supply To learn more about
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like a whole team is supporting your staff during
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Medline is a registered trademark of Medline Industries, Inc. ©2007 Medline Industries, Inc.
Mundelein, IL 60060 Improving Quality of Care Based on CMS Guidelines 17
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Crossword Puzzle
Understanding Skin Tears:
the “Whys” and “Hows”

hour of
To receive one r your
CE credit, entene at
answers onli
1 2 3

7 8 9


11 12



15 16 17




21 22
1. Register (free) or log in
2. Click Free Courses tab
3. Locate the puzzle and click
Learn More, then Begin Course
4. Certificates are available online
after puzzle completion

JBK2_HSV_v8.qxd:Layout 1 8/24/07 9:12 PM Page 19

Across Down
2 Choose dressings that keep the wound 1 The dermis and epidermis move as one in
optimally moist without causing further _____ young skin.
_____. 3 Skin tears occur most commonly in the
5 Between the epidermis and dermis is the _____ extremities.
_____ membrane, a moving junction that 4 It is _____ to look at dressing choices and
both separates and attaches the epidermis choose products that allow you to avoid
and the dermis. adhesives, decrease dressing changes and
6 Keeping the patient well _____ can be the maintain a moist wound healing environment.
difference between a bruise, a bump and a 6 Advancing age and a _____ of previous
skin tear. skin tears put residents at risk for skin tears.
7 Remember key measures such as cleaning, 8 To protect the injury during dressing
moisturizing and nourishing the skin with change, indicate the _____ in which the
advanced skincare _____. dressing should be removed.
10 There are several _____ products that can 9 The _____ has an irregular shape
help alleviate the discomfort of skin tears. resembling downward, finger-like projections
11 As skin ages, the rete ridges or pegs begin called rete ridges or pegs.
to _____ between the dermal-epidermal 12 _____ skincare products that deliver
junctions. endermic nutrition and antioxidants can
13 When injury occurs, there is an increase in assist in preventing skin tears.
_____ absorbed by the skin. 14 _____ handling of skin tears in important.
15 Skin tears cause a resident to suffer _____. 16 Dermal-epidermal flattening is typically
16 Certain medications, such as _____, can seen by the _____ decade of life.
make the skin more prone to injury. 17 Hydration and the appropriate _____ are
18 The use of protective sleeves or elastic the key objectives to healing and
tubular support bandages can help to preventing skin tears.
_____ dressings in place. 19 Skin tears of _____ origin make up one half
19 The dermis has _____ projections. of the total skin tear population.
20 It is estimated that at least 1.5 _____ skin 21 Patients and residents who are totally
tears occur in institutionalized elderly each dependent on others for activities of daily
year. living are at the _____ risk for skin tears.
21 One dressing that can handle the initial 22 Compromised nutrition, fluid volume deficit,
fluid is a _____ sheet. confusion, limitations in mobility, lack of
independence and ecchymotic skin are all
_____ for skin tears.

Improving Quality of Care Based on CMS Guidelines 19

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Survey Readiness

Can you explain the differences between these commonly confused terms?

Prevalence or incidence? Mattress overlay or mattress replacement?

Prevalence refers to the proportion of a population Mattress overlays are pressure-reducing support sur-
(such as nursing home residents) who are affected with faces placed on top of an existing mattress. They can be
a particular disease at a given time. filled with air, foam, gel, water or a combination thereof.
Incidence refers to the rate of occurrence of new cases Mattress replacements, also pressure-reducing support
of a particular disease in the population being studied. 1
surfaces, are made of high-quality foam or other materi-
als and actually replace the inner-spring mattress directly
on the bed frame. They provide pressure relief that is not
Avoidable or unavoidable pressure ulcer?
possible with standard hospital mattresses.3
Avoidable pressure ulcer refers to a facility’s failure to
do one or more of the following: evaluate the resident’s
clinical condition and pressure ulcer risk factors; define Friction or shear?
and implement interventions that are consistent with Friction refers to resistance to movement.
resident needs, resident goals and recognized standards Shear refers to disruption of the connection between soft
or practice; monitor and evaluate the impact of the inter- tissue and bone.3
ventions or revise the interventions as appropriate.
Unavoidable pressure ulcers occur despite the facility
evaluating the resident’s clinical condition and pressure
ulcer risk factors; defining and implementing interventions
consistent with resident needs, goals and recognized
standards of practice; monitoring and evaluating the impact
of the interventions and revised approaches as appropriate.2

1 Merriam-Webster’s Medical Dictionary. Available at: Accessed August 15, 2007.
2 Centers for Medicare & Medicaid Services. CMS Manual System: Pub. 100-07 State Operations. Available at:
downloads/R4SOM.pdf . Accessed August 15, 2007.
3 Medline Industries, Inc. The Wound Care Handbook. 2007.

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Staff development coordinators frequently ask for

in-service on lung sounds and how to document them.
Rales, rhonchi and wheezes can be confusing and
difficult to describe. Tear out this article to help you
understand what you are hearing and what these
sounds mean for your patients’ health and care.

What’s that noise?

Your guide to assessing
lung sounds By Ellie Armstrong, LPN

Know what’s normal

Large populations of geriatric patients have some type of a respiratory
diagnosis. Chronic obstructive pulmonary disease (COPD), emphysema,
asthma and congestive heart failure (CHF) can all affect normal lung
sounds. It is important to note what patients’ normal lung sounds are,
especially since patients with limited mobility are prone to respiratory
infections. Assessing patients’ lung sounds on a daily basis can help
you know right away when something isn’t “normal.”

Assessment should include breath sounds, respiratory rate, heart rate

and respiratory pattern. If the patient has a cough, note if it is dry or
productive. If the patient has a productive cough, note the color, texture
and amount of sputum produced. Also check the patient’s oximetry for
a baseline.

Hints for listening

Auscultation of lung sounds should be done in a quiet environment
whenever possible. The patient should be sitting up in bed. If this is not
an option, lung sounds may be assessed with the patient lying on their
side. Breath sounds are best heard when there is no interference from
clothing, so place the stethoscope on the patient’s bare skin.

Auscultation should be done on all lobes, moving from left to right for a
minimum of two to four breaths. This enables comparison of the lobes to
each other and time to listen for abnormal or adventitious sounds.

Improving Quality of Care Based on CMS Guidelines 23

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Bronchial or vesicular? Coarse crackles are usually louder, lower in pitch and
Normal lung sounds are described as bronchial or vesicu- longer in duration than fine crackles. The most common
lar. Bronchial sounds are what are heard over the large conditions associated with coarse crackles are CHF and
airways. These sounds have been compared to the sound bronchitis. Coarse crackles have been described as similar
of air being blown through a tube. They are louder at the to the sound opening a Velcro® fastener would make.
expiratory phase. Bronchial sounds can be heard over the
tracheal area, over the lung apices and between the Rhonchi are continuous sounds, as they usually last more
scapulas. than one quarter of a second. Rhonchi can be described
as a coarse rattling sound, somewhat like snoring, and
Vesicular sounds are heard over the chest, away from are usually caused by secretions in the larger airways.
large airways. These sounds have been compared to the They usually clear with coughing. These sounds can be
sound of wind blowing through the trees. Vesicular sounds heard in patients with chronic COPD and acute or
are decreased in patients with COPD and over sites severe bronchitis.
of pneumonia.
Wheezes are high-pitched whistling sounds often
Absent or diminished? described as musical. Bronchospasm, airway edema,
Abnormal breath sounds are classified as absent or secretions, endobronchial tumors and compression of the
diminished. Absent breath sounds are just what the name airway can cause this adventitious sound. It might also be
suggests – they are inaudible. Diminished breath sounds heard in patients with CHF due to increased fluid in the
have softer-than-typical loudness. These sounds can peribronchial lymphatics, causing airway compression.
reflect reduced airflow to a portion of the lungs, overinfla-
tion of a segment of the lungs (such as with emphysema), Know your resident
air or fluid around the lungs and even increased thickness The lung sounds described above are the most commonly
of the chest wall. A decrease in the intensity of sounds in heard lung sounds. Knowing your residents’ normal lung
a given area can be the first sign of a disease process. sounds and being able to assess changes will be a
valuable tool for their care.
“Adventitious” another word for “abnormal”
Rales, rhonchi and wheezes are the most common of
adventitious lung sounds. Pleural rubs and stridor are also
classified as adventitious, but are less commonly heard.

Rales, also called crackles, are caused by the explosive

openings of small airways. They have been described as
being similar to the crackling sound that wood makes as it
burns. Crackles are most commonly heard during the
inspiratory phase of breathing, although they can be About the author
heard during the expiratory phase also. Crackles are Ellie Armstrong, LPN, regularly in-services healthcare
associated with inflammation or infection of the small professionals on the proper way to listen to, describe and
bronchi, bronchioles and alveoli. Crackles that don’t clear document lung sounds in long-term care facilities. She
with coughing might indicate pulmonary edema or fluid has been an LPN for more than 26 years and currently
trapped in the alveoli due to CHF or ARDS. serves as head of the clinical department at Enos Home
Oxygen and Medical Supply, Inc.
Crackles can be categorized as fine or coarse. Fine crack-
les are generally higher pitched, less intense and shorter
in duration than coarse crackles. Fine crackles are usually
heard in the late inspiratory phase. The sound of fine
crackles can be simulated by rolling a strand of hair
between fingers near the ear.

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JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:25 PM Page 26

By Scott A. Kale, MD, JD, MS

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:25 PM Page 27

Special Features

Take a second to think

about the average
healthcare facility.
Bacteria, viruses and fungi are everywhere. They are on the walls, in the
beds and on the sinks. They are on the sheets, the gowns and the books.

Although I could go on with this travelogue of the residences of infectious

organisms, let’s talk about the one place we least want these creatures
lurking – our hands. These creatures are on the hands (and the clothing
and jewelry) of the doctors, the nurses, the clerks, the visitors. They are
ubiquitous and they are dangerous. staphylococcal
What’s the problem?
An estimated 103,000 people die every year from healthcare-acquired
infections related to poor staff hygiene. This is a greater annual cause
of mortality than AIDS, breast cancer and automobile accidents
combined. Nearly 75 percent of patient rooms are contaminated with
a drug-resistant staphylococcal organism. Fewer than 50 percent of
physicians wash their hands between patients, let alone wash them
properly. Programs emphasizing hand hygiene have been largely ineffective
and beneficial doctor-nurse “debugging” behaviors remain elusive.

The increased use of alcohol-based hand rubs (the use of which is

standard practice in European hospitals) has improved the rate of hand-
washing compliance somewhat, but even these products must be used
intelligently (before each contact), in the proper volume (3ccs), for the
requisite period (18 seconds to 27 seconds, compared to one to two
minutes for soap) and over the necessary surfaces (hands and wrists).

One would think that medical school training and passing knowledge
of germ theory and simple handwashing strategies would conspire to
eliminate iatrogenic risks. One would be wrong.

Americans are not big handwashers in the first place (only 83 percent
wash their hands after using a restroom, for example, and more than
40 percent don’t wash after coughing or sneezing) or they wash incorrectly
(for fewer than 20 seconds) when they bother to wash at all.

Improving Quality of Care Based on CMS Guidelines 27
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:26 PM Page 28

While they are not diligent or reliable
hand-washers, Americans are enthusi-
astic handshakers, and thereby cordially
pass on their shigella (diarrhea), kleb-
facilities because of a willingness of
their staffs to follow infection risk-
reduction protocols, obey mandated
cleaning of rooms and equipment,
siella (wound infections), Haemophilus wear disposable gowns and, of course, An estimated
(conjunctivitis), E. coli (urinary tract
infections), pseudomonas (infections),
wash their hands. American healthcare
administrators contend that enforcing
bacteroides (infection), Influenza A cleanliness rules is too expensive and people die
(pneumonia), Clostridium difficile difficult. Apparently, it is easier and
(colitis), assorted rhinoviruses (upper perversely acceptable to allow one in
every year
respiratory infections/colds) and 20 hospital patients to contract an from HAIs
staphylococcus (infection), among infection than it is to solve the infection
other critters. Apparently, physicians problem with its associated human and related to
and nurses – being typical American financial losses.
poor staff
workers – have chalked up their own
set of dire statistics by disregarding There has been a visible public move- hygiene.
handwashing, as evidenced by the ment toward self-protection. DVDs,
outrageous iatrogenic death rates books and the Internet all tout aggres-
in hospitals. sive methods of keeping yourself – and
your loved ones – safe in healthcare
What’s the solution? facilities. It would appear too few
So, what can we do? Certainly, the people are taking advantage of them.
problems associated with ineffective
hand hygiene are well recognized. Perhaps we should enlist patients
Even the Illinois General Assembly has
expressed concern, introducing a bill
in February 2007 that would require
Influenza A
and their families to help eradicate
infection risk. Residents can speak up
and tell their caregivers that they want
schoolchildren to wash their hands doctors to have clean hands before
with antiseptic soap before eating. touching them. We have actually creat-
Politicians, including President Bush, ed a large blue button printed with
Vice President Cheney, Al Gore and “Please wash your hands, my health
Barack Obama carry hand sanitizers depends on it” that can be fastened to
with them at all times to help reduce patient gowns. Residents should also
their risk of infection during glad-handing be encouraged to speak these very
season (which is now perpetual). words to every caregiver with whom

Scandinavian countries have been more

successful than the United States at
reducing deadly infections in healthcare
they come into contact.

A large V.A. study demonstrated that

patient-initiated doctor handwashing
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:26 PM Page 29

on a surgical ward is highly effective

at reducing healthcare-acquired
About the author
infections. We have created an entire Scott A. Kale, MD, JD, MS, is in the private
kit (“The Advo Kit”) that is given to practice of internal medicine and rheumatol-
ogy. He is an attending physician on the staffs
each patient. It introduces these and of Rush University Medical Center and Saint
other proactive protective behaviors Joseph hospitals. He is a Fellow of the
Institute of Medicine and the immediate past
for hospitalized people. Included in our
chairman of the board of directors of the
approach is the requirement that the DePaul University College of Law’s healthcare
patient provide a “score” for their policy division. He is also a non-practicing
attorney with extensive experience in
caregivers. An individual score is evaluating medical malpractice, including cases
recorded for each doctor or nurse. involving decubitus ulcers. His strong interest
in medical risk reduction centers on using
The score reflects the caregiver’s
awareness of past errors to design improved
hygiene skills, and the grades are systems of medical care.
shared with the caregivers. The
prospect of being graded will change
behavior in the desirable direction.
1. Widmer AF. Replace hand washing with use of a
waterless alcohol hand rub? Clin. Infect. Dis.
It is my understanding that previous 2000;31:136-143.
methods have largely failed to change 2. Rotter M. Hand washing and hand disinfection
[Chapter 87]. In: Mayhall CG, ed. Hospital epidemiol-
the frequency and intensity of the ogy and infection control. 2nd ed. Philadelphia, Pa:
hand-washing behaviors of our staffs. Lippincott Williams & Wilkins, 1999.
3. Chicago Tribune, Metro North section, Thursday,
If it is true that more than 100,000 February 15, 2007, page 8.
deaths each year is insufficient motiva- 4.Trick WE, Vernon MO, Hayes RA et al. Impact of
ring wearing on hand contamination and compari-

tion to incite a change in hygiene son of hand hygiene agents in a hospital. Clin. Infect.
Dis. 2003 Jun 1;36(11):1383-90.
tactics and methods, then something
as simple as the proverbial “gold star”
or “ A+” issued to caregivers might be.
If administrative directives cannot
remediate washing performance,
perhaps simply honoring patient
requests will.

All we have to lose by trying a simple

method of behavior modification are
the germs.

o viruses
Improving Quality of Care Based on CMS Guidelines 29
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:26 PM Page 30

Sterillium® Comfort Gel®

Your hands will

love you even

Also available:
Sterillium Rub
for surgical hand

Do more with less

Sterillium Comfort Gel delivers greater efficacy than other alcohol-based hand antiseptics*
by virtue of its ethyl alcohol concentration, and it does more for your infection control efforts

that Sterillium Comfort Gel achieves reductions of ≥ 5 log10 (≥ 99.999 percent) on a broad
by using up to 50 percent less volume per application.* Independent in vitro testing demonstrated

range of nosocomial pathogens.*

Add comfort for compliance

Sterillium Comfort Gel’s incredible bactericidal effect doesn’t matter if the product isn’t being used!
You’ll want to reach for Sterillium Comfort Gel again and again because it includes a balanced blend Available in three
of moisturizing emollients that leverages technology shared with BODE Chemie by its parent packaging styles
company Beiersdorf AG, makers of well-known skincare products NIVEA® and Eucerin®. to suit any need,
The result is a product proven to increase skin hydration by 14 percent in just two weeks.* including a touchless
dispensing option.
Increased efficacy. Incredible comfort. Improved compliance.
Sterillium Comfort Gel.
©2007 Medline Industries, Inc. Medline® is a registered trademark of Medline Industries, Inc. Contact your
Sterillium® is a registered trademark of BODE Chemie GmbH.
NIVEA and Eucerin are registered trademarks of Beiersdorf AG. Medline representative
Sterillium® Comfort Gel® is a registered trademark of Bode Chemie GmbH. or call 1-800-MEDLINE
*Data on file
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:26 PM Page 31

Special Features

The Key to Hand Hygiene

Have you tried alcohol-based hand gels?
Appropriate hand hygiene is the most important
action that can be taken in the battle to prevent
cross transmission of nosocomial pathogens to
susceptible residents. Transmission of these
pathogens can lead to colonization, infection
and even death.1 Alcohol-based hand rubs are
widely considered to be the most appropriate
type of agent for every situation in which hands
are not visibly soiled.2 However, several factors
need to be considered when determining the
best possible protection for residents.

Efficacy and dosage

Both efficacy and dosage should be considered
to selecting an appropriate hand antiseptic.
Hands of healthcare workers are mainly colonized
with bacteria and yeasts.1 That is why a hand
antiseptic should have the optimum efficacy
against these pathogens. Alcohol-based gels
with 85 percent ethyl alcohol fulfill the efficacy
requirements.4 Yet clinicians challenge manufac-
turers to formulate with emollient technology
designed to deliver good skin care and offset
concerns they have with the dermal aspects of
alcohol use.

Another factor is dosage. The efficacy of hand

antiseptics is often studied with aliquots of
3 or 5 mL, but the amounts used in clinical
practice are largely unknown and it is unlikely
that they are as high as 5 mL. Recent unpublished

By Mary Beth Fry, BS, CIC

Improving Quality of Care Based on CMS Guidelines 31

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:26 PM Page 32

evidence suggests that an aliquot as small as 2.4 should be functional. In a recent study, only
mL might well be sufficient to cover both hands 77 percent of a certain type of wall dispenser
with the preparation and also fulfill U.S. efficacy were found to be functional after 16 months.6
requirements, especially if the preparation has A malfunctioning or difficult-to-use wall dispenser
a high ethyl alcohol content. From a practical is likely to discourage healthcare workers to
point of view, and given the nature of the clinicians’ perform hand antisepsis. Pocket bottles provided
work environment – where time is short and to staff serve dual purposes. Their availability
patient load is demanding – products that can leads to increased compliance and reduces the
deliver required efficacy with minimal application amount of “contraband” product brought into
volume are desirable. facilities without the necessary compatibility
testing typically required.
Dermal tolerance
Handwashing contributes to irritant contact Key conclusions
dermatitis on the hands of healthcare workers, Appropriate selection of a hand antiseptic –
which can result in dry and rough skin, redness including taking into account its dispensing
and loss of integrity of the skin barrier. That technology and packaging configuration – is key
is why it is crucial to wash hands only when in achieving optimum efficacy and comfortable
absolutely necessary. In all other clinical situa- use of hand antiseptics. Meeting these goals will
tions, an alcohol-based hand antiseptic should likely have an impact on patient safety.
be applied to decontaminate hands. The hand
About the author
antiseptic should not be sticky and should ideally
Mary Beth Fry, BS, CIC, is currently the infection
improve the skin condition, e.g., by reducing
control coordinator at the University of Illinois Medical
skin roughness or increasing skin hydration,4
Center, Chicago, Ill. She has more than 32 years of
which can increase the hand hygiene compliance
experience as a clinical microbiologist and with all
rate.5 If a preparation is unpleasant or uncom-
aspects of infection control.
fortable to use, it will likely be rejected by health-
care workers. This can result in a low compliance
rate and, ultimately, cross transmission of noso- 1. Kampf G, Kramer A. Epidemiologic background of hand hygiene
comial pathogens. As a result, while implement- and evaluation of the most important agents for scrubs and rubs.
Clinical Microbiology Reviews. 2004;17(4):863-893.
ing a good hand hygiene program is intended to 2. Boyce JM, Pittet D. Guideline for hand hygiene in healthcare set-
tings. Recommendations of the healthcare infection control practices
have a positive impact on infection rates, product advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene
selection decisions can lead to the opposite task force. Morbidity & Mortality Weekly Report. 2002;51:1-45.
3. Kampf G, Rudolf M, Labadie J-C, Barrett SP. Spectrum of antimicro-
effect if the products are perceived by staff to be bial activity and user acceptability of the hand disinfectant agent
Sterillium Gel. Journal of Hospital Infection. 2002;52(2):141-147.
damaging to the skin and therefore go unused. 4. Kampf G, Muscatiello M, Häntschel D, Rudolf M. Dermal tolerance
and effect on skin hydration of a new ethanol-based hand gel. Journal
of Hospital Infection. 2002;52(4):297-301.
Easy access 5. Kampf G. The six golden rules to improve compliance
in hand hygiene. Journal of Hospital Infection. 2004;56
In addition to being effective and gentle on (Suppl. 2) :S3-S5.
the skin, hand antiseptics must be easily and 6. Kohan C, Ligi C, Dumigan DG, Boyce JM. The importance of evalu-
ating product dispensers when selecting alcohol-based handrubs.
conveniently available. Pocket bottles and wall American Journal of Infection Control. 2002;30(6):373-375.

dispensers are two simple ways to achieve this.

A wall dispenser should be easy to use and

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:26 PM Page 33

Pulse Oximetry
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of Medline Industries, Inc.
Improving Quality of Care Based on CMS Guidelines 33
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Seat Cushions:
Padding Your
Pressure Ulcer
Prevention Strategy
Cynthia Fleck

Diane L. Holland
BS, PT, CWS, WCC, C. Ped.

JBK2_HSV_v8.qxd:Layout 1 8/28/07 1:28 PM Page 35


Pressure ulcers can occur when a client is lying down or in a

seated position. Wheelchairs and other seated surfaces, which
are sometimes an afterthought, could be the missing link in a
comprehensive care plan that mandates individualized care.

CMS Tag F314 Frequently asked questions two inches of space behind the knees. It
states, “Appropriate
support surfaces or
devices should be
1 Why are they called “bedsores”
when pressure ulcers also occur
in seated individuals?
is important that the leg rest height is
correct so the client’s knees are not
positioned too high. Also, a client’s thighs
chosen by matching Approximately 68 percent of pressure
should be adequately supported. This will
a device’s potential ulcers occur on the pelvis and are the
distribute the pressure load and decrease
therapeutic benefit result of sitting upright.2 Clients who are
pressure on the ischial and sacral areas.
with the resident’s confined to a wheelchair for a significant
specific situation.”1 amount of time during the day are at
It is essential to look at issues such as
hypertonicity (high muscle tone) and
highest risk. Individuals with comorbidities
intervene to control and improve position-
such as diabetes, renal and respiratory
ing. A client with limited range of motion
failure, poor hydration and nutritional
(ROM), such as decreased hip rotation,
concerns are also in danger of developing
will compensate with postural changes
a pressure ulcer. Even a client with good
in the torso. In this case physical therapy
sitting posture can experience skin
or a referral to a positioning professional
breakdown. Common locations where
may be needed for assessment and
pressure ulcers develop when confined
wheelchair modification. Wheelchairs
to a wheelchair are the sacral area (tail
with sling seat upholstery should be
bone) and ischial tuberosities (sitting
discouraged when clients spend a
bones). Skin breakdown may also be
substantial amount of time in a wheelchair.
related to an individual’s body structure
The sling causes internal rotation of the
and to the atrophy or loss of muscle
femurs (legs), adduction (rolling inward)
from nonuse.
of the lower extremity, a posterior pelvic
tilt (sliding down) and a kyphotic trunk
Clients can sit in a wheelchair for more
(slouched over) posture. Over a period of
than 16 hours a day; therefore, a combina-
time this can lead to decreased range of
tion of interventions must be implemented
motion, scoliosis and decreased function
and assessed when ordering a new
and weakness in the abdominal and
wheelchair cushion. The primary goal of
spinal musculature.3,4
a wheelchair pressure redistribution device
is to evenly spread pressure over a larger
area. Pressure by itself does not cause
a pressure ulcer; peak pressures that
What are the different types of
wheelchair cushions and which
one is the best?
reduce circulation cause them. To help
There are many pressure redistributing
prevent skin breakdown, a wheelchair
devices on the market that vary in cost
and wheelchair cushion must fit the client
and quality. Most of the larger wheelchair
in width, support the thighs and leave

Improving Quality of Care Based on CMS Guidelines 35

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:27 PM Page 36

cushion manufacturers offer a range of

cushions that differ in pressure redistribu-
tion, support and functional needs. A proper
Why do some wheelchair cushions
need a piece of wood inserted
beneath them?
6What should we teach our clients when
they are restricted to a wheelchair?
This can be a very important piece of the
assessment and follow up is necessary The upholstery in wheelchairs “slings” or puzzle that healthcare professionals might
to determine changes in function that may “sags” when you sit on it. A cushion will be missing. Sometimes we offer a client a
require modification to the wheelchair and also sag and cause poor positioning by cushion or pressure redistributing device
wheelchair cushion. producing internal rotation and adduction but offer little to no follow up. Individuals
of the femurs, which causes torso insta- who use a wheelchair and/or a wheelchair
The majority of wheelchair cushions on bility. The wood or solid seat insert will cushion need to be taught to move out of
the market are made out of foam, layers decrease the amount of sag in the wheel- the wheelchair and inspect the skin on
of multi-density foam, gel, a combination chair, improving the foundation and the their buttocks. Reinforcement of proper
of multi-density foam and gel, silicone client’s posture. Some wheelchairs have pressure relief techniques and weight-
and varying densities of silicone material solid frames and do not fold; therefore, a shifting every 15 minutes is imperative.9
and air. The air cushions are either solid wood insert is not needed.

powered or non-powered. There are Cushions wear out, go flat and do not
also custom wheelchair cushions and I didn’t realize the number of cushions perform optimally forever. We would not
backs as well. that are available and the various uses dream of purchasing a new automobile
for them. Is there any way to make it and never changing the oil, having a
Published studies have compared several less confusing? tune-up or checking the tire pressure,
types of cushions by judging their ability Wheelchair cushions can be confusing right? Yet, often this is what happens
to prevent skin redness or by measuring and wheelchair positioning and pressure after a cushion is purchased. This can
interface pressure, which is the pressure relief is a specialty in its own right. mean problems for the user and potential
that occurs when a body comes in contact Choice is important because a cushion pressure ulcers and other challenges.

with a surface or cushion. The over- should last for an extended period of time.
whelming result of this research indicates Other factors that must be considered What is “bottoming out” and why do
that no single cushion is best for all when ordering a cushion include conti- I need to check the cushion all of
people.5 It depends on the client and nence, transfers, amount of time per day the time?
their particular needs. spent in the wheelchair, muscle tone and It is important to check the cushion

mobility. Another issue to consider is client every day to determine if it has bottomed
I have seen egg crate and foam rings compliance and choice. Educating the out. That may seem excessive but if the
used, are they suitable? client on the cushion and evaluating client is not “floating” on the surface or
Foam or air “invalid” rings are not which products improve position, offer suspended, their tissue and bony areas
appropriate for pressure reduction.6,7 effective pressure reduction, optimize are not being protected. To test for bot-
The ring increases pressure around function and offer versatility for transfers toming out, simply don a glove and slide
the sacral region and decreases blood and daily life are important steps. Your your hand between the client and the
flow, which may cause problems. The facility’s rehabilitation department or a cushion. If it is difficult to do, you can
ring can also cause deep tissue injury to wheelchair clinic in the community is a good place your hand inside a pillowcase to
a high-risk client because the unnatural place to start. Look for a Rehabilitation help it slide under the client more easily.
shape does not conform to the anatomy Engineering and Assistive Technology There should be about an inch of material
of the buttocks. Additionally, egg crate Society of North America (RESNA) (air, gel, fluid, foam, etc.) between the
cushions offer no pressure relief and certified clinician or technician. To become client and the bottom of the surface.
can bottom out, causing the client to certified they must study and pass a rigorous Have you ever stayed at a motel and
touch the bottom of the wheelchair and exam in this specialty area. Once certified, slept on a bed with the springs poking
not float on the surface. These products they are trained in wheelchair assessment you in the back all night? That is
should be avoided. and proper wheelchair selection and often bottoming out.
utilize special computerized mats to assess
a client’s needs.8

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:27 PM Page 37


The client’s skin should be checked for suppliers who have Certified Rehabilitation Cynthia A. Fleck,
persistent redness each time they are Technology Suppliers, or the credential MBA, BSN, RN,
moved. This will measure whether the CRTS. These individuals have passed a
cushion is doing its job and whether rigorous credentialing exam and have at
FCCWS is a certified
weight shifts or moving the client back least two years of experience. They can wound specialist and
to bed should be done more frequently. be found by visiting the National Registry dermatology advanced

of Rehabilitation Technology Suppliers practice nurse, author,
What are the surveyors looking for (NRRTS) Web site at speaker, Secretary/Treasurer of the American
Academy of Wound Management (AAWM),
and what does CMS state? Another legitimate credential is the
Member of the Board of Directors of the
Key information regarding repositioning Assistive Technology Supplier (ATS),
Association for the Advancement of Wound
and assessment of a client’s skin integrity, certified by RESNA.12 Care (AAWC), Diplomat of the American
especially in the immobile, is emphasized Professional Wound Care Association and
in the CMS Guidance to Surveyors.11 Clinicians who are Assistive Technology Vice President, Clinical Marketing for Medline
Appropriate support surfaces should be Practitioner (ATP) certified provide Industries, Inc., Advanced Skin and Wound
Care Division. Cynthia can be reached at
utilized wherever the client’s skin is in analysis of a client’s needs with regard
contact with a surface area for a prolonged to all areas of seating, positioning and
period of time (beds, mattresses, chairs, assistive technology. These individuals Diane L. Holland, BS,
wheelchairs, etc.). The document further must possess a minimum of an associate’s PT, CWS, WCC, C. Ped
describes the use of sheepskin-type degree and three years’ experience in is a physical therapist
products, pillows and wedges and warns his or her field, such as physical or and Certified Wound
Care Specialist practicing
that they should only be used for comfort occupational therapy.
at Bellevue Hospital in
or reduction of friction, not pressure
New York City. She was
redistribution. The use of donut-type formerly employed at
cushions is not recommended, nor are the Hospital for Joint Diseases, Diabetic Foot
wheelchairs with sling seats that may Center, also in New York City. Diane can be
not be optimal for prolonged sitting during reached at

activities or meals.

The following recommendations are

quoted directly from the CMS Guidance
for Surveyors for Pressure Ulcers.11
— An at-risk resident who sits too long 1 Department of Health and Human Services. Centers for Medicare and Medicaid Services.
on a static surface may be more CMS Manual System Pub. 100-07 State Operations Provider Certification. November 12, 2004.
2 Bryant RA, eds. Acute and Chronic Wounds: Nursing Management. 2nd ed. St. Louis, Mo:
prone to get ischial ulceration. Mosby Yearbook, Inc.; 2000.
— Slouching in a chair may predispose 3 Schmeler M, Byning M. The Lecture Series on Application and Use of Wheelchair Technology Seating
Biomechanics Lecture. WheelchairNet. Department of Rehabilitation Science and Technology. Oct.1999.
an at-risk resident to pressure ulcers 4 Carison MJ, Payette MJ, Vervena LP. Seating orthosis design for prevention of decubitus ulcers.
of the spine, scapula, or elbow, (elbow Journal of Orthotists and Prosthetists. 1995;7(2):51-60.
5 Sprigle S. The match game. Team Rehab Report. May 1992:20-21.
ulceration is often related to arm rests 6 Panel for the Prediction and Prevention of Pressure Ulcers in Adults: Pressure Ulcers in Adults: Prediction
or lap boards). and Prevention. Clinical Practice Guidelines, No. 3. AHCPR Publication No. 92-0047. Rockville, Md: Agency
for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.
— Friction and shear are also important May 1992. Available at: Accessed August 21, 2007.
factors in tissue ischemia, necrosis 7 Ratliff C, Bryant D. Guideline for Prevention and Management of Pressure Ulcers. WOCN Clinical Practice
Guideline Series, No. 2. Wound, Ostomy and Continence Nurses Society. Available at:
and pressure ulcer formation. Accessed August 21, 2007.

8 Fleck CA. Under pressure. Advance for Providers of Post Acute Care. November/December 2004:64-65.
9 Fleck CA. Pressure ulcers: risk, causes and prevention. ECPN. November 2005;105(9):32-40.
Who can help? 10 Fleck CA. The new cms pressure ulcer guidelines. ECPN. January/February 2005:36-42.
Again, clinicians and providers with 11 Department of Health and Human Services. Centers for Medicare and Medicaid Services.
CMS Manual System Pub. 100-07 State Operations Provider Certification. November 12, 2004.
expertise in seating and positioning 12 Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).
should be a part of the team. Look for Available at: Accessed August 21, 2007.

Improving Quality of Care Based on CMS Guidelines 37

JBK2_HSV_v8.qxd:Layout 1 8/28/07 1:29 PM Page 38

IN What is urinary incontinence?

Urinary incontinence refers to the inability to control the passage
of urine. This can range from the occasional leakage of urine to a
complete inability to hold any urine. In fact, urinary incontinence can

be broken down into seven types:

Incontinence can • Stress incontinence: Occurs when sudden pressure is applied to

leave your residents
the bladder, causing urine to leak out. This can happen during
feeling embarrassed
or alone – but it exercising, coughing, sneezing, laughing or lifting, for example.
shouldn’t! In fact, • Urge incontinence: Describes the frequent, sudden urge to urinate

it’s estimated that with little control over the bladder (also known as overactive bladder,
25 million Americans spastic bladder or reflex incontinence).
will experience
transient or chronic • Overflow incontinence: Residents with overflow incontinence
incontinence.1 cannot completely empty their bladders. This leads to frequent
urination or a constant dribbling of urine, or both.
Why not take a • Functional incontinence: This is the most common type of

moment to review
incontinence among elderly residents with arthritis, Parkinson’s
the facts on
incontinence? disease or Alzheimer’s disease. The limitations these residents
Perhaps doing so have with moving, thinking or communicating make them unable
will mean that to effectively control their bladders.
you’ll have just • Mixed incontinence: Residents experiencing mixed incontinence
the right words
have two types of incontinence simultaneously, typically stress

to reassure
incontinence and urge incontinence. The causes of the two forms
your residents!
of incontinence are not necessarily related.
• Temporary incontinence: Can be caused by severe constipation,
infections in the urinary tract or vagina or by certain medications,
such as diuretics, narcotics, antihistamines, antidepressants or
calcium channel blockers.2

CE: Reassuring residents

that they’re not alone.
What causes incontinence?
There are a number of reasons that incontinence develops – and,
contrary to what many people think, it’s not a normal part of the
aging process. Common causes of incontinence include:
• Weak bladder
• Weakened muscles around the bladder (common in women who
have given birth)
• A blocked urinary passageway
• Damage to the nerves responsible for controlling the bladder
• Diseases that limit movement, such as arthritis3
1 Resnick NM. Improving treatment of urinary incontinence
(commentary letter). JAMA. 1998:280(23):2034-35.
Reassuring the incontinent resident
Despite how common incontinence is or what is causing it,
2 Mayo Clinic. Types of urinary incontinence. Available at: Accessed
residents who are experiencing incontinence might feel
August 14, 2007. embarrassed or ashamed. Here are several tips for comforting them
3 U.S. Food and Drug Administration. Coping with bladder and maintaining their dignity.
problems. Available at:
Accessed August 14, 2007. • Remember that toileting accidents are embarrassing.
4 Washington State Department of Social and Health Services. • Stay calm and reassure the resident that it is OK.
Caregivers’ handbook. Available at:
Publications/22-277.pdf. Accessed August 15, 2007. • Maintain a matter-of-fact approach, using phrases such as
“Let me help you get out of these wet things.” 4
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:27 PM Page 39

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The revolutionary
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JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:27 PM Page 40

JBK2_HSV_v8.qxd:Layout 1 8/28/07 2:07 PM Page 41


Taking the

F e a r out of
Male Catheterization By Victor Senese, RN, CURN

T his is a true story that took place about 10 years ago. I was paged to see a patient in the
hospital for a urethral catheter insertion. I introduced myself to him and he frantically told me,
"You’re the third person trying to get this catheter in!" I learned a staff nurse and a resident had
already tried and failed to insert a catheter into his distended bladder, and he was not looking
forward to my poking around. Half kidding, I told him I am an expert and I can insert this
catheter in “one shot.” He took me up on my bet and, sure enough, I was able to insert his
catheter in one try.

So, how did I do it?

At that time I had been practicing urology nursing for more than a decade and had inserted a
lot of urinary catheters. Obviously, I learned a few tricks in the catheterization of males. I am
also the nurse called upon when everyone else gives up trying to place the catheter. Here are
some simple tips that all nurses can apply to their daily practice.

The first thing I do is introduce myself to the patient and inform him I am an “expert” in
catheterization. Now, I know everyone isn't an expert, but it helps if the patient thinks you are.
I learned early on that nobody wants to be your first patient. Whether you're an expert or a
novice, this introduction goes a long way in relaxing an apprehensive patient. Remember, the
sphincter is under voluntary control. If a nervous patient tightens up, catheterizations can
become a cruel tug-of-war, with the patient’s sphincter often winning. Now that the patient is
convinced I know what I am doing, I explain the procedure to him. Most men like to be in con-
trol and want involvement in this procedure, so why not get them involved?

Improving Quality of Care Based on CMS Guidelines 41

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:27 PM Page 42

When available, I instill 2 percent lidocaine jelly into the urethra. If this is not available or your
institution doesn't allow this practice, instill a water-soluble lubricant into the urethra. A catheter-
tip syringe will work nicely for this. Use about 5 to 10 cc. The lubricant acts to dilate the urethra
as well as lubricate the passage. Next, place the catheter into the urethral opening and instruct
the patient to relax the muscles in his legs. The sphincter and leg muscles are both skeletal
muscles and relaxing the legs will help relax the sphincter. Advance the catheter with a steady
pressure. Stop if you meet resistance.

Catheterization Recommendations

1 Recommendation #1: If you feel resistance, rest your arm against the patient's leg and ask
him to relax. When you feel the leg muscle relax against your arm, push the catheter forward
and it will probably slide right in.

2 Recommendation #2: Be sure to insert the catheter up to the balloon’s “Y” port. Don't
assume that if you see urine the catheter is in. Examine a Foley catheter and you will notice
the drainage islets are in front of the balloon. If you assume the catheter is in because you
see urine, you might inflate the balloon in his prostate! Profuse bleeding usually follows this
careless act.

3 Recommendation #3:Assess your patient for balloon size. An elderly gentleman can easily
pull a 5 cc balloon to his prostate. I usually prefer to use a 30 cc balloon catheter on all males
and inflate the balloon to 15 to 30 cc, depending on the patient's level of orientation.

4 Recommendation #4:Tape that tube! The last step is to secure the tube to the patient's leg
with tape. This will prevent accidental trauma to the bladder, and is often the most overlooked
step in catheterization.

5 Recommendation #5:: A coudé catheter is often disregarded. It is designed with a slight

curve at the end to facilitate the passage around an enlarged prostate. If you encounter resist-
ance just before the bladder, the prostate is probably enlarged and a coudé catheter will get
you by it easily.

Occasionally you will not be able to pass a catheter due to strictures or scars found within the
urethra. This is when you need to call it quits and request your fellow urologist. If you follow my
recommendations you will probably be able to insert urinary catheters into most patients.

I still routinely see that patient from the hospital in our office. He has taken to calling me by the
nickname "One Shot" and brags to anyone who will listen about that eventful day when I was
able to get a catheter into his bladder in one try!

About the author

Victor Senese has been a nurse for 25 years, is a past president of the Society of Urologic
Nurses and Associates and is currently employed as a urology nurse clinician in Oak Lawn, Ill.

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:28 PM Page 43

SILVERtouch ™
Foley Catheter
Let us help you fight to eliminate catheter-associated urinary tract infections.

The clinical rationale

According to the CDC, catheter-associated urinary tract
infection (CAUTI) is the most common hospital-acquired
infection. Each year, more than 1 million patients in
U.S. extended- and acute-care facilities acquire such an
infection; the risk with short-term catheterization is 5
percent per day. CAUTI is the second most common
cause of nosocomial bloodstream infection, and studies
suggest that patients with CAUTI have an increased
institutional death rate, unrelated to the development
of urosepsis. Catheters coated with silver alloy/hydrogel
have recently been introduced into practice, and a
growing body of literature supports their use in a
variety of clinical settings.1
UTIs account for 40 percent of
hospital-acquired infections2
80 percent of nosocomial UTIs are
catheter-associated (CAUTI)3, 4

Healthcare facilities have adopted prevention strategies to minimize the risk of

CAUTI. In addition to emphasizing good practice supported by CDC guidelines,
coated catheters are routinely being utilized to improve patient outcomes.

➤ Silvertouch catheters contain silver; every Silvertouch

catheter is coated inside and out with ionic silver.
Silver is well recognized as a broad-spectrum
antimicrobial effective against gram-positive and
gram-negative bacteria, including resistant strains
such as MRSA and VRE.
➤ Silvertouch catheters are more comfortable due to
a hydrophilic coating that hydrates quickly and
maintains its lubricity for at least a week.
➤ Silvertouch catheters are latex-free and are 100 percent
silicone, so both caregivers and patients are kept safe.

1. Rupp M et al. Effect of silver-coated urinary catheters. AJIC.
To learn more, contact your Medline 2004;32(8):445-50.
2. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nation-wide
representative, call 1-800-MEDLINE or nosocomial infection rate. A new need for vital statistics. Am J Epidemiol.
visit 1985;121:159-67.
3. Paradisi F, Corti G, Mangani V. Urosepsis in the critical care unit.
Crit Care Clin. 1998;14:165-80.
©2007 Medline Industries, Inc. Mundelein, IL 60060 4. Vincent JL, Bihari D, Suter PM, et al. The prevalence of nosocomial
Medline is a registered trademark of Medline Industries, Inc. infection in intensive care units in Europe—The results of the EPIC study.
Silvertouch is a trademark of Medline Industries, Inc. JAMA. 1995;274:639-44.
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:28 PM Page 44

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• Standard Precautions Policy and Procedure

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JBK2_HSV_v8.qxd:Layout 1 8/28/07 2:07 PM Page 45

Special Features

If the shoe fits …

Diabetic feet
need special

Have you ever worn a pair of shoes only to find

your feet hurting because the shoes have caused
a blister or other injury? What do you do when this
happens? Most of the time you probably do not
consider this a problem; you just put on another
pair of shoes or a bandage strip. However, if you
have decreased sensation to your lower extremities,
including your feet, this could be an emergency.
Decreased sensation is called neuropathy and is
the leading cause of foot wounds in
people with diabetes mellitus (DM).

By Joyce Norman, BSN, RN, CWOCN

Improving Quality of Care Based on CMS Guidelines 45

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:28 PM Page 46

What causes neuropathy? how to determine changes in sensa- to three times per year, and podiatric
The most common causes for loss of tion with the use of a monofilament care every 61 days. These benefits
sensation are neuropathies related to and other tools. When these subtle help prevent further damage.
diabetes mellitus, but it can also be changes start to occur, it is appropri-
related to alcoholic neuropathy, herpes, ate to obtain proper footwear. The Inspection & protection
cancer and spinal cord lesions. footwear should fit well and help to The importance of inspecting and
Neuropathy is a change in sensation maintain proper alignment of the foot. protecting diabetic feet cannot
as a result of nerve damage that can be overemphasized.
cause an individual to have no feeling Beyond neuropathy
or an increase in pain. The client may Another problem that occurs with It is important to be aware of the feet,
describe symptoms such as burning, poorly controlled DM is neuromuscu- the changes in the feet and what can
tingling and unusual pain. Traditional lar changes that affect the structure be done to protect the feet. Simple
pain medications are often not effec- and form of the feet. The toes can daily inspection and protection can
tive, making other medications, treat- start to hammer and have other make a huge difference.
ments and modalities necessary. deformities, and the foot itself can
change in appearance and form,
Danger ahead which affects the ability of the patient
Managing a patient with diminished to wear regular shoes. Working with
or no sensation can be dangerous a doctor of podiatric medicine (DPM),
and difficult. The patient may be orthotist or pedorthotist is important
unaware of items in or on their because they can help to accommo-
footwear and may continue to wear date footwear and align the foot so
shoes that cause injuries, have for- that the changes in structure do not
eign objects in them or that simply cause ulcers and damage. When
do not fit correctly. Because of the orthotics and other accommodations
lack of sensation caused by neuropa- of the footwear are not enough,
thy, the patient does not feel the special shoes may be necessary.
source of the problem, continues to Depending on the degree of damage
wear improper footwear until there to the foot, the patient may be able to
are apparent signs of injury such as purchase them or they may need to
odor, drainage adhering to footwear, be custom-made.
or a problem controlling their blood
sugar levels. Other features that can help protect
the feet are well-fitting footwear with a
Injury can be avoided deep toe box in the shoe to decrease
The problem with diabetes mellitus is rubbing and reduce undue injury to
that these complications do not have the foot. The footwear can be a
to occur. Literature indicates that as sandal-type or full shoe, with devices
many as 80 percent of ulcers could built in or attached to help keep pres-
be preventable. In fact, they are usually sure off of the affected area. When a
related to poor management of the client has accommodative foot wear
disease over time. The disease has it is not the end of the condition.
an impact on many systems. Because Footwear needs to be reexamined
of the damage to the small vessels, on a regular basis depending on
the eyes, kidneys, heart and peripheral the wear and amount of damage to
system can be affected. As the the foot. An individual with diabetes
complications worsen and an individual should see their healthcare profes-
loses the ability to feel their feet, sional at least annually.
diligent monitoring is essential.
CMS has recognized the importance
Someone with DM should have their of proper footwear and provides cov-
feet examined at least once a year by erage under Medicare for one to two
a professional healthcare provider. shoes per foot per year, insoles or
The clinician needs to be trained in orthotics for better foot alignment up

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:28 PM Page 47
JBK2_HSV_v8.qxd:Layout 1 8/28/07 2:07 PM Page 48

Survey Readiness

Could this help

your facility?
By Pat Rodecker, RN, WCC

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:28 PM Page 49

Nathan Littauer Hospital and Nursing treatment regimen. We considered this

Home, located in Gloversville, N.Y., an appropriate setting to reinforce the Staff completed the
recently joined with Community Health importance of using it daily to keep the following wound care
Center to promote consistent wound residents’ skin moist. competency questions:
care. We began by assembling a
team of experts who agreed to work
together to make clinical wound
Calazime® Protectant Paste is used on
some of our residents and staff had
1 Name four areas of the body
that are at high risk for
care improvements. commented that it was thick and hard skin breakdown.
to remove. To overcome this obstacle,
At the team’s first meeting, a list of prod-
ucts used in each setting was created to
the application of Calazime was demon-
strated, stressing that a thin layer was
2 Name two reasons that patients
would be at high risk for skin
cross-reference and ensure consistency all that was needed. breakdown.
when patients transitioned from one
setting to another. The primary focus
then turned to education. The team
Another exercise included a demonstra-
tion with hydrocolloid dressings. Some
3 Name four ways to relieve/prevent
pressure ulcers.
insisted that improved wound care were shown leaking and another was
education would be necessary to pro-
vide appropriate, effective care. To this
shown rolled off the ulcer. CNAs were
asked which dressings they would
4 When would you report to a nurse
that your patient needs a
end, a wound care competency day report to the nurse for changing. dressing change?
was planned. Samples of the various wound care

The wound care competency day was

products that we use in our facilities
were included at this station with
5 You are assisting a resident with
lunch who typically eats only 25
split into two sections. In the morning, demonstrations on how to apply and percent to 50 percent of their
a skincare representative was on hand remove them. Finally, we reviewed flow meal. Of the following foods,
to educate the clinical nurse specialists sheets that are used for documentation. which three should you encourage
(CNSs) on the proper use of skin- We ended by answering any specific them to consume first to provide
cleansing products. In the afternoon, questions from the staff relating to either them with the most calories
a lecture on liability and wound care a product or specific resident problem. and protein:
was held. a. Coffee w/sugar
Heel Protection Station b. Fortified pudding
Now that we have given you an idea of The next station was heel protection. c. Tuna sandwich
how the day was structured, we would Heel pain is a common complaint; d. Canned peaches
like to share what we feel made our therefore we felt is an important subject e. Green beans
wound care competency day a success. to address. Padded booties were shown f. 8 oz. whole milk
Perhaps your own facility would benefit to provide protection from shear; howev-
from a similar experience! er, they are not appropriate for pressure
relief. Heel relieving booties were shown had spilled milk and food pushed
Skincare Station to the staff and application was demon- around on the plate but not eaten. Our
First was a review of Medline’s Soothe strated to ensure proper placement of goal was to see if the staff realized this
& Cool® No Rinse Hair/Body Wash. We the heel. Staff was reminded to inspect should not be included in the percentage
determined that certified nursing assis- their resident’s feet daily and report taken. Dietary personnel included a
tants (CNAs) wanted residents’ bath concerns to the nurse. thorough explanation of the dietary
water to have suds. Education was program “every bite counts” (EBC).
provided to the staff indicating that it Dietary Station Certain foods are fortified and the staff
was not necessary to have suds. A The dietary station featured resident was instructed to encourage residents
plan was then put in place to provide food trays. Each person was asked to to take these foods first (high calorie
consistent reminders to reinforce and look at the tray that was presented and and high protein).
assist with this practice change. then compare it with the next three trays.
They were then asked to assess what Play Detective Station
Medline’s Soothe & Cool moisturizing percentage of the meal was taken. The last nursing station was fun. We
cream had recently been added to our Included in this display was a tray that placed a mannequin in a patient bed

Improving Quality of Care Based on CMS Guidelines 49

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:28 PM Page 50

to point out multiple potentials for skin

breakdown. Our mannequin was lying Evaluation form
on Foley tubing, wearing wet briefs, had
on heel booties that were not properly 1 Identify pressure areas of the body.
placed, wound drainage on the skin,
lying on a bedpan with crumbs in the 2 Recognize potential causes of skin breakdown.

bed. If that was not enough, the O2 tubing

was not padded and the head of bed 3 State how proper nutrition is important to the wound
healing process.
was elevated to 90 degrees. The turn
4 Identify conditions and report the need for a dressing

and position flow sheet at the bedside
change to a nurse (CNA).
was not signed. The staff really enjoyed
seeing how many things they could
find wrong and comparing results with
5 Identify wound ad/or dressing conditions that indicate
the need for a dressing change (LPN/RN).
one another as to how well they did.
6 Discuss documentation requirements for wound

Participants who recognized all of the assessment and care (LPN/RN).
potentials for skin breakdown were
given a small prize.

Physical therapy provided a visual display About the author

Pat Rodecker, RN, WCC is the
of proper positioning in a wheelchair.
clinical coordinator at Nathan Littauer
This included back and feet positioning.
Hospital and Nursing Home.
They also stressed the need to reposition
at-risk wheelchair residents every hour.

The votes are in: “Hands On” Is a

great way to learn and review!
The day was well attended by nursing
home staff. The 11 p.m. to 7 a.m. nurs-
ing home staff attended after their shift
was over. The 7 a.m. to 3 p.m. staff
covered the floor for each other and the
3 p.m. to 11 p.m. shifts attended when
they arrived on duty. The hospital staff
who attended felt they learned a lot,
although we did make a plan to improve
their attendance at our next educational
workshop. The workshop required about
one-half hour for each person to go
through all the stations. Setting up did
not take too long, either. Resources
included a nurse at the three stations,
a dietary staff person and someone
from physical therapy to be available.
The evaluations indicated that staff did
increase their ability to identify potential
pressure areas on the body and under-
stand how to use the products we have
available in our facility. Responses
ranged from “good” to “excellent” and
the staff said it was worth attending
and would like more workshops like this.

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:29 PM Page 51

Janet Jones

Got a question? Call 1-888-701-SKIN (7456)

Q “I have a partial thickness wound related to incontinence but I can’t get

a hydrocolloid to stick in the area. Can you help?”

It is very difficult to get a physical dressing to stick when incontinence
is an issue. Repeated use of a physical dressing is usually ineffective
and often leads to additional skin damage such as shearing. The dressing
becomes wet and slides against the skin. Or breakdown from the skin
injury occurs because of prolonged contact with the now contaminated
dressing. However, it is certainly necessary to cover the injured skin,
protecting it from further assault by urine and stool.

Choose a barrier designed for wet skin “... spread the paste
(Second Generation Barrier Paste) as a protective layer.”
A barrier paste designed for wet skin, sometimes called second generation
barrier, is an excellent option. Not all barriers are designed for this purpose –
look for ingredients such as zinc, karaya, calamine or menthol and indications
that read “for wet or weepy skin.” This type of barrier is a very durable paste
and will not wash off even with repeated episodes of incontinence, thus OR SKIN CARE QUESTION?
creating a “physical dressing.” If turning and repositioning are appropriately
Call the Educare Hotline! Medline’s
done, healing usually occurs without any difficulty.
toll-free hotline is supervised by a
Helpful hints board-certified enterostomal therapy/
Some important tips when using a second generation barrier: wound, ostomy and continence nurse.
> 1. When applying the product it is important not to rub the product in;
spread the paste as a protective layer.
> 2. It is important when cleansing the area to merely clean off the urine or
Just pick up the phone and call
stool. If any barrier cream residue remains on the skin, merely apply 1-888-701-SKIN (7456).
another thin layer of barrier cream on top.
We’re here to help!
> 3. Remember scrubbing can lead to further skin injury.
> 4. Cleanse and reapply once or twice a day.
> 5. Education is necessary so that the product is utilized correctly.
About the Author
Janet Jones, BSN, RN, PHN,
A second generation barrier cream is an excellent option when dealing with CWOCN, DAPWCA is a board-
superficial injury to the skin and continence issues are a problem. certified wound, ostomy and
continence nurse. She has
extensive experience in long-term
See you on the Hotline! and home care and has developed
wound prevention and treatment
programs for many national healthcare groups. She’s also
ready to take your call on Medline’s Educare Hotline!
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:29 PM Page 52

A I R - P E R M E A B L E P R E M I U M D R Y PA D

The power of ONE


1 pad
The innovative backsheet on
for healthier skin: ONE
1 pad for easier care:
can be used on both
allows air to flow standard beds and air-support
through the pad while still acting as a therapy beds.
barrier to moisture.* The result is superior
skin dryness and comfort. Advanced Technology

1 pad for lower cost:
are so strong and
absorbent that they eliminate the need
for multiple pads. They can also reduce
Soft, Non-Woven Topsheet AquaShield Film
the need for draw sheets, linens or – softer against skin for – traps moisture, providing
increased comfort better leakage protection
reusable underpads. This results in a
Advanced SuperCore® Innovative Backsheet
dramatically lower cost. Absorbent Sheet – air permeability
– thermo-bonded to provide better means better skin comfort
*MVTR of 3600 +- 1000 g/m2/24h
pad integrity and superior skin dryness

©2007 Medline Industries, Inc.

Medline and Ultrasorbs are registered trademarks of Medline Industries, Inc.
SuperCore is a registered trademark of McAirlaid’s Vliesstoffe GmbH & Co. 1-800-MEDLINE
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:29 PM Page 53

Perineal Skin Care for

the Incontinent Resident
Decision tree for skin care based on the information from Minimum Data Set (MDS) 2.0
continence status.

Three simple steps for selecting the best skincare product:

>> 1. Decide where the resident fits into the “continence” definition of MDS 2.0 Section H.1
>> 2. Assess the resident’s current skin condition
>> 3. Locate the closest description on the grid

0 1 2 3 4
Continent Usually Occasionally Frequently Incontinent
Includes use of Continent Incontinent Incontinent Has inadequate
indwelling urinary Bladder – Bladder – two or Bladder – two control.
catheter or ostomy incontinent more times a week, or more times a Bladder – multiple
device that does episodes once a but not daily; Bowel week, but not daily episodes;
not leak stool week or less; Bowel – once a week daily; Bowel – Bowel – almost all
– less than weekly once a week the time

Skin Condition: Intact, Reddened or Chapped Skin

Moisturize/ Cleanse

Cleansing wipes or Remedy™ 4-in-1 Cleansers

Remedy Dimethicone

Moisture Barrier or Remedy Nutrashield

Remedy Skin Repair Cream

Skin Condition: Dry, Ready-to-Tear Skin

Moisturize/ Cleanse

Remedy 4-in-1 Cleansers

Remedy Dimethicone

Moisture Barrier or Remedy Nutrashield

Remedy Skin Repair Cream

Skin Condition: Macerated or Denuded Skin

Fungal Moisturize/ Cleanse

Remedy 4-in-1 Cleansers

Infection Protect

Remedy Calazime Protectant Paste

Remedy Antifungal Cream or Powder

Improving Quality of Care Based on CMS Guidelines 53
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:29 PM Page 54

Case Study
Using Olivamine* in a Skin Cream to
Improve Skin Quality in Diabetic Patients
By Dawn R. Fortna, RN, CDF, CWOCN
Ephrata Community Hospital, Ephrata, Pa.
Our diabetic population presents with skin
is 91-year-old female has had type 2 diabetes for more than 20 years. She presents with
issues often resulting in skin injury and
xerosis, fine lines, scaling and pain in her legs, which is increased at night (Figure 1a). She
increased costs. Autonomic neuropathy causes
describes the pain as “deep pain” and scores it as a number “8” on the scale of 0-10 . Since
a decrease in the sweat and oil production,
daily application of the Olivamine-containing product, she has had no xerosis, fine lines
resulting in xerosis. Our goal was to decrease
and scaling have decreased and her skin appears much healthier. She states that the pain
these issues and costs of secondary injuries
resolves completely for several hours after application of the product (Figure 1b).
and improve quality of life for our patients.

Fifty patients were selected to participate in a
skincare product trial. Criteria for inclusion
was a diagnosis of diabetes, high risk for skin
breakdown and characteristics of xerosis,
defined as abnormally dry skin with fine lines,
scaling and fissures. Untreated xerosis may lead
to itching and scratching, pain and cellulitis.
Excluded were confused or non-verbal
patients. Skin cream containing Olivamine was Figure 1a Figure 1b
applied daily to the patients’ legs and feet,
after cleansing, for a period of four weeks. Skin PM
was evaluated weekly for integrity. Pain was is 63-year-old female has had type 2 diabetes for approximately five years. She also has
documented using a 0-10 pain scale. Patients troublesome venous stasis disease and has an ongoing battle with severe xerosis, scaling
were queried regarding itchiness. and cracking of skin (Figure 2a). She has little sensation in her legs, so pain has not been
a major problem. However, since she is using the Olivamine product daily, she states that
OUTCOMES she has “less of a pulling sensation” on her legs. Daily cleansing, moisturizing and protecting
Olivamine delivers amino acids, antioxidants the skin with the Olivamine-containing product has greatly improved the general condition
(hydroxytyrosol), vitamins and methylsul- of her skin (Figure 2b).
famethane to the skin. Transepidermal water
loss (TEWL) is preserved with dimethicone base,
preventing damage from dehydration and
decreasing pruritis.

A program of cleansing, moisturizing, and
protecting the skin with the Olivamine-
containing product improved skin outcomes
including skin integrity, prevention of break-
down of fragile skin and decreased pain and Figure 2a Figure 2b
itching for patients.
is 46-year-old male has had type 2 diabetes for more than 10 years. He has had multiple
toe amputations and additional foot surgeries due to osteomyelitis. He presents with a
recent surgical incision from amputation of a metatarsal head and is presently under treat-
ment with a podiatrist and WOCN. He has experienced xerosis, scaling and cracking of skin
and itching (Figures 3a and 3b). He has noticed marked improvement of his symptoms
with daily application of the Olivamine product (Figure 3c).

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:29 PM Page 55


Figure 3a Figure 3b
1. Bale S, Harding K, Leaper DJ. An introduction
to wounds. London: Emap Healthcare, 2000.
2. Fore J. A review of skin and the effects
of aging on skin structure and function.
Ostomy Wound Manage. 2006;52(9):24-35.
3. Diabetes mellitus and wound healing.
Available at:
Accessed June 21, 2005.
4. Holland D, Fleck C. Skin assessment in
patients with diabetes. ECPN. 100(4);30-36.
5. Preventing foot complications in patients
with diabetes. Available at: Accessed
August 22, 2007.
6. Remedy. Available at:
Figure 3c remedy. Accessed August 22, 2007.
7. Scarborough-Roessler P. Keeping the foot
attached to the leg. Presentation. January
Assessed Criteria Patients meeting Improved after 2003. Educators 2000 Plus.
Criteria 4 weeks 8. Van Gills C, Stark L. Diabetes mellitus
XEROSIS 47 47 (100%) and the elderly: special considerations for
FINE LINES 50 50 (100%) foot ulcer prevention and care. Ostomy
SCALING OF SKIN 40 40 (100%) Wound Manage. 2006;52(9):50-56.
ITCHING 26 22 (84.6%)
PAIN 4 4 (100%)

All participants in the study exhibited improvement of the initial xerosis, fine lines and
scaling of skin while 84.6 percent of those who identified initial itching experienced
decreased itching following daily application of the Olivamine product.e participants
stated that they noticed immediate results and stated how good the skin felt with
application of the product. Upon assessment, the skin integrity appeared to be much
improved and no patient in the study had further skin breakdown or infection.
Patients experiencing neuropathic pain, of which there were only 4 in the study, all
experienced pain reduction of at least 3-4 points on the 0-10 pain scale after application
of the Olivamine product. e small number of participants with pain as a major concern
is likely due to the number of patients with diabetes and their sensory neuropathy.
Many of those with sensory neuropathy have either masked pain or are insensate. ere
are obvious limitations to the effect of any product regarding pain in this study. ese
results demonstrate that a program of cleansing, moisturizing and protecting the skin
with the Olivamine-containing product improved skin outcomes including skin integrity,
prevention of breakdown of fragile skin and decreased pain and itching for patients.
e quality of life issues are evident by the number of participants who inquired about
purchasing the product as a result of their satisfaction with the product’s results.

*Remedy Skin Repair Cream with Olivamine from

Medline Industries, Inc. Mundelein, Ill. Remedy is
a registered trademark of Medline Industries.

Improving Quality of Care Based on CMS Guidelines 55

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Improving pain
management at
your facility

In both the QIO’s Nursing Home Quality Initiative and Advancing Excellence in
America’s Nursing Homes, clinical performance measures and clinical goals include
improvement in pain management.

Below are 15 pain management improvement strategies for your team to consider!
1. Design a facility admission tool that includes a question on whether the resident has
any pain.
2. Institute pain screening tools appropriate for cognitively impaired residents and create a
easy-to-carry pocket card.
3. Designate responsibility and accountability to specific staff positions for screening of pain at
admission and periodically thereafter as part of routine interaction with residents.
4. Promote pain as the “fifth vital sign” among all staff – screen for pain just as you would
for breathing.
5. Educate all nursing staff, including CNAs, about pain symptoms in the elderly.
6. Involve the patient and family and stress the importance of their working with staff to assure
appropriate pain management.
7. Test staff members’ competencies in performing pain evaluation.
8. Use standardized evaluation tools, including pain-rating scales, to evaluate residents’
complaints of pain.
9. Develop a procedure for incorporating information obtained during pain evaluation into the
resident care plan.
10. Prescribe pain medications on a regular (versus PRN) basis for individuals with daily pain.
11. Educate all staff, including nurses and physicians, on good pain management and provide
guidelines at each nurses’ desk.
12. Incorporate non-pharmacologic approaches to pain management. (e.g., relaxation, hot or
cold packs, acupuncture, etc.).
13. Conduct regular in-services about pain management, focusing on myths of pain, the elderly
and pain medications.
14. Implement a procedure for contacting and communicating with clinicians (MD, MP or PA)
about residents who continue to have pain after starting treatment.
15. Create a schedule for monitoring pain and response to pain management
(e.g., after each dose of pain medication).

Reference: Nursing Home Improvement Collaborative: Pain Management Handbook. Available at:
Accessed August 16, 2007.

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© 2007 Medline Industries, Inc. Remedy is a trademark

of Medline Industries, Inc. Medline is a registered trade-
mark of Medline Industries, inc.
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The Barrier Product

for the 21st Century
The inside of an adult incontinent brief is a hostile Another advantage to silicone is that it feels smooth,
environment for the skin. Assaulted by urine, fecal less greasy and lasts longer than traditional petro-
enzymes and bacteria, the skin of the incontinent latum products, even when washed.
resident needs all the help it can get. Traditionally,
this has come in the form of petrolatum barriers, Three features of silicone barriers offer distinct
with or without zinc oxide or other ingredients. advantages over petrolatum barriers, particularly
The paste or film spread over the skin would form white pastes that include zinc oxide.
a barrier between the skin and the moisture and 1. Very little dimethicone barrier is necessary to
chemicals trying to break it down. spread a thin film over the skin, so a tube will
last a long time.
Disadvantages of petrolatum barriers 2. Because it is a cream rather than a paste, it
• Greasy/messy glides smoothly over the skin, reducing the
• Occlusive to the skin, perhaps preventing pain of spreading a thicker compound that
normal function of the skin will later have to be scrubbed to be removed.
• Pastes that are opaque prevent viewing of With improved focus on pain reduction in
the skin facilities, silicones will become more common.
• Pastes that are thick can be difficult to clean off 3. Because most dimethicone barriers are clear
• Petrolatum barriers can affect the effectiveness once dry, the skin below the barrier can be
of absorbent incontinence products by viewed and monitored without having to be
clogging the facing wiped off.

Silicone, the petrolatum alternative

Silicones have become prevalent in the past 15
years as moisture barriers for incontinence. These
inert polymers are strong compounds that are not
broken down by water or chemicals. The most
familiar is dimethicone, which is combined with an
alcohol that evaporates, leaving behind a thin, dry
film that protects against moisture, maceration,
urine and enzymes. This type of material is still
breathable, allowing the skin to act normally.

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:30 PM Page 59

Comfort-Aire™ Disposable Briefs from Medline

Because Their Dignity Matters

W e don’t have to tell you how important Skin Safe
it is that the disposable brief you chose pro- Tape Tabs

vides a feeling of confidence and dignity. Breathable

Side Panels
Nothing matters more. At the same time
you’d hope for a solution that works on
more than one level. Just one touch
and you know Super
Comfort-Aire™ Absorbent
disposable briefs
are unique. Extra-
soft side panels allow
better airflow for
enhanced comfort and
improved skin care. The comfy Soft Cloth-like
outer cover helps prevent irritation. Outer Cover

But that’s not all. Comfort-Aire’s enhanced, super-

absorbent core keeps skin dry. And dry, healthy skin For more information
provides both dignity and comfort. Isn’t that what on Comfort-Aire,
contact your Medline
you want most from a disposable brief ?
representative or call
©2007 Medline Industries, Inc. Medline is a registered trademark & Comfort-Aire is a trademark of Medline Industries, Inc.
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:30 PM Page 60

Love Them
2 Products designed for you
and your residents

As a professional in the long-term care field, you perform a delicate balancing

act every day you’re on the job – taking care of your residents while
caring for yourself. Your ultimate goal, of course, is to deliver the best
possible care to your residents–but when great products help make that easier,
everybody wins!

In this edition of Healthy Skin, we’re excited to introduce you to two products
whose implementation can benefit all involved!
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:30 PM Page 61

Survey Readiness

Exuderm® OdorShield™ Ultrasorbs® AP

Resident dignity is a hot topic – and it’s a legal right of all nursing It’s no secret that incontinence can be embarrassing to residents.
home residents. The Nursing Home Reform Act, part of the And with an estimated 25 million Americans experiencing transient
Omnibus Budget Reconciliation Act of 1987, established The or chronic incontinence, it’s incredibly common.3
Residents’ Bill of Rights, among which are “the right to accom-
modation of medical, physical, psychological and social needs” Some incontinence management products do little to ease
and “the right to be treated with dignity.”1 embarrassment. Underpads can tear easily, leak or allow wetness
to remain in contact with resident skin, potentially leading to
Wound malodor, in addition to being commonly associated with irritation or complications to wounds in the sacral area.
chronic and infected wounds, can affect residents socially and
psychologically. In extreme incidences, it can even lead individuals Ultrasorbs AP from Medline are different. The innovative backsheet
to withdraw from social contact, even with family and friends. 2
on these underpads allows air to flow through the pad while still
Yes, a number of odor-absorbing hydrocolloid dressings are acting as a barrier to moisture. The result? Superior skin dryness
available on the market, but Exuderm OdorShield is unique. and comfort. In addition, the thermo-bonded SuperCore®
Unlike any other hydrocolloid, this patented, advanced wicks moisture away from the skin and locks fluid away,
product is designed to absorb odors from matter that is increasing dignity and improving odor control and skin care.
exuded from wounds. In fact, the odor-absorbing compo-
nent of Exuderm OdorShield – cyclodextrins – are even According to the Wound, Ostomy, and Continence Nurses
used in consumer products such as Febreze® to control Society (WOCN), these results are desirable – and recom-
odors. This represents a major improvement over traditional mended. In their 2003 Guideline for Prevention and
charcoal-based, odor-absorbing dressings, which have a Management of Pressure Ulcers, the WOCN recommended
limited capacity for odor control. selecting “underpads, diapers, or briefs that are absorbent to wick
effluent away from the skin.”4
In addition to its odor-absorbing benefits, Exuderm OdorShield
has other features of equal benefit to residents and long-term This is great news for the resident, and there are benefits for staff
care professionals. Because it is translucent, it allows easy as well. Because Ultrasorbs AP are super strong, they’re resistant
visualization of the wound without removing the dressing. And to tearing. They’re also extra absorbent–in fact, one Ultrasorbs AP
its smooth satin backing, tapered edge and low-residue formula has the absorbing power of three or more standard underpads.
ensure that it is long-wearing.
Ultrasorbs AP are also versatile. Because they are completely
But you don’t have to take our word for it – Exuderm OdorShield breathable, they can be used on both standard beds and air-
was recently awarded the 2007 Medical Design Excellence support therapy beds. They’re also suitable for absorbing ongoing
Award (MDEA) in the category “General Hospital Devices and fluid loss or anywhere else skin dryness is desired.
Therapeutic Products.” These awards recognize the achievements
of medical device companies responsible for creating innovative To learn more about either of these products, contact
products that improve healthcare delivery, increase effectiveness your Medline representative, visit or
of existing medical practices and ultimately provide enhanced call 1-800-MEDLINE.
benefits to the patient.
1 AARP. The 1987 Nursing Home Reform Act fact sheet. Available at:
Exuderm OdorShield was developed and is manufactured by
Avery Dennison Medical™. It is exclusively marketed in the
import-687-FS84.html. Accessed August 16, 2007.
United States by Medline Industries, Inc. 2 Van Toller S. Psychological consequences arising from the malodours
produced by skin ulcers. Proceedings of 2nd European Conference
on Advances in Wound Management.1993;70-71.
3 Resnick NM. Improving treatment of urinary incontinence
(commentary letter). JAMA. 1998:280(23):2034-35.
4 Wound, Ostomy, and Continence Nurses Society (WOCN).
Guideline for Prevention and Management of Pressure Ulcers.
Glenview, Ill.: Wound, Ostomy, and Continence Nurses Society
(WOCN); 2003.

Improving Quality of Care Based on CMS Guidelines 61

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• Introducing Medline's New Green Tree line of toilet paper and hand towels made of 100
percent recycled material ... because we care.
• Medline is doing their share to help the environment. Can we count on you to help?
• Ask your Medline rep for more details about this program.

Green Tree is a trademark of Medline Industries, Inc

Call 1-800-MEDLINE
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:30 PM Page 63

Cool tips
Aluminum Energy
• By recycling one aluminum can per • Keep the temperature of your water
day, we can save enough energy to heater at home down to 120 degrees
operate a television set for Fahrenheit. It will be hot enough for
three hours. everyday use but will keep energy
usage lower.
Automobiles • Invest in a programmable thermostat
• Three major items from our to make adjustments for you when
automobiles cause problems in you are not home or when you are
landfills: oil, tires and car batteries. sleeping at night.
Recycle motor oil with local oil and • Unplug an underutilized freezer
lube shops so that it can be used in or refrigerator.
commercial operations as fuel. If your
local recycling facility accepts tires, the Paper
rubber can be used for playgrounds, • Think before you print a document –
flooring, asphalt or burned as fuel. do you really need a paper copy?
Car batteries contain lead and sulfuric If so, is there an economy print mode
acid – but all elements can be reused on your printer that will use less ink?
in new batteries. • Paperless billing – having statements
• Share a ride with coworker or friend sent to your email address and
and you’ll cut your emissions in half. paying your bills online eliminates
paper, stamps, envelopes, etc.
• Put your computer in sleep mode Trees
when you are not using it. • Plant a tree. If every American family
• Do not add electronic waste to planted one tree, more than a billion
landfills. A computer monitor, for pounds of greenhouse gases
example, might be 6 percent lead would be removed from the
by weight. atmosphere every year.

• Recycle glass – the energy saved from
one glass bottle will light a 100-watt
light bulb for four hours.

Cool tips
Improving Quality of Care Based on CMS Guidelines 63
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by Jeannine Thompson
Clinical Education Specialist

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Special Features

Among Alice’s challenges:

1. A locked door and an unobtainable key.
2. Tweedle Dee and Tweedle Dum who were more concerned about themselves
than with listening to what Alice had to say.
3. Magical mushroom pieces without instructions.
4. The Mad Hatter and the March Hare’s tea party, where they celebrated
un-birthdays instead of birthdays, wasting Alice’s time.
5. A forest full of confusing signs.
6. Gardeners who had Alice help paint white roses red to cover-up
their mistakes.

Do you remember 7. The queen who blamed Alice for everything bad that had happened to her.
the story of Alice 8. A court hearing where the witnesses were of no help to Alice.

in Wonderland? Ultimately, Alice never did catch the white rabbit.

Alice wanted to find

Anurse in WOUNDerland:
the white rabbit. So, The clinician’s Alice in Wonderland
without thinking, she Like Alice, Anurse can jump into wound care without thinking. And, also like
jumped into a deep hole. Alice, Anurse may encounter many challenges and detours during her quest to
provide an optimal moist wound healing environment to promote the closure of
Alice encountered many
a pressure ulcer.
challenges and detours
during her quest to find 1. An unobtainable “key” dressing needed for healing.
the white rabbit. 2. Associates who care more about their own agendas than listening to what
Anurse has to say.
3. Wound care products that lack instructions for use.
4. Healthcare professionals who practice unconventional wound care instead
of care based on clinical research, which can cause Anurse to waste her time.
5. Literature that can be confusing.
6. Associates who want to cover up sub-optimal care.
7. State and federal surveyors who may not see the whole picture.
8. Associates who are of no help in court.

Ultimately, the pressure ulcer does not heal.

During Alice’s adventure, she meets a very wise Cheshire cat. Being lost, she
asks the cat which way she should go. “That depends upon where you want to go,”
responds the cat. Alice says, “It really doesn’t matter.” To which the cat replies,
“Then it really doesn’t matter which way you go.”

In pressure ulcer care, the “where do you want to go?’’ question

represents wound closure and how Anurse reaches that goal does

Improving Quality of Care Based on CMS Guidelines 65

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:31 PM Page 66

matter – physically, financially Anurse can no longer waste her time with the Mad Hatter and March Hare and not reach
and emotionally. the goal in a reasonable amount of time. Becoming aware that the pressure ulcer has
Alice didn’t have a global position- not progressed at the time of discharge, end of the certification period, when the state
ing system to help her get from her surveyors review the charts or when the lawyers appear at the facility is unacceptable.
home to the rabbit, but Anurse
does. All Anurse has to do is use How can you show healing?
the reliable and validated pressure Validated assessment tools that use objective data to monitor pressure ulcer progression
ulcer healing tools that have been can help determine if a specific treatment modality is appropriate.
provided to her.
Anurse knows the three phases of wound healing are inflammatory, proliferative and
Using the GPS system model, maturation. Anurse also knows that the inflammatory phase typically begins on day
Anurse inputs the starting and one and lasts for five days, the proliferative phase typically begins on day five and lasts
ending destinations and the best until day 25, and the maturation phase typically begins on day 25 and lasts up to18
way to get there in the plan of care. months. In general, a clean pressure ulcer with adequate blood supply and innervation
If the wound does not progress as should show evidence of stabilization or some healing within two to four weeks. However,
planned, the GPS system alerts many pressure ulcer healing rates are like Alice’s white rabbit, who states “I’m late,
Anurse immediately. I’m late for a very important date,” thus making them chronic ulcers, which can linger
for weeks, months and even years.
Anurse is already proficient in assess-
ment, planning and implementation, Validated tools for monitoring pressure ulcer healing have existed since 1997. The
but what about timely evaluation? Pressure Ulcer Scale for Healing (PUSH), the Sussman Wound Healing Tool (SWHT)
and the Bates-Jensen Wound Assessment Tool (formerly known as the Pressure Sore
Pay for Performance (P4P) is here. Status Tool (PSST)) can be Anurse’s pressure ulcer GPS. If Anurse uses a monitoring
Poor healthcare practices will no tool on a routine basis, usually weekly, to assess the progression of the pressure ulcer,
longer be paid for. Documentation she will know if the wound is progressing through the inflammatory phase as expected.
must indicate that Anurse’s treatment If the tool indicates slow to no progression, Anurse knows that she needs to notify the
modality is appropriate for the doctor that a change to the plan of care might be necessary to promote healing and
pressure ulcer and that the pressure move the wound out of the inflammatory phase.
ulcer is progressing positively.
As the assessment continues to be charted using a monitoring tool, Anurse can deter-
mine if the pressure ulcer is progressing through the proliferative phase. If the pressure
ulcer is not progressing, Anurse will contact the physician to change the plan of care to
promote collagen synthesis, formation of new blood vessels, formation of granulation
tissue and epithelialization.

If a pressure ulcer is not progressing and the clinician decides to continue the current
plan of care, the rationale for the decision should be documented.

PUSH Tool 3.0

A useful tool for monitoring the change of a pressure ulcer over time is the PUSH tool,
developed by the National Pressure Ulcer Advisory Panel (NPUAP).

To use the PUSH Tool, the pressure ulcer is assessed and scored on the following
three elements:
1. Length x Width is measured and scored from 0 to 10
2. Exudate Amount is scored from 0 (none) to 3 (heavy)
3. Tissue Type is assessed and scored from 0 (closed) to 4 (necrotic tissue)

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:31 PM Page 67

Each element is assigned a number, which is then added together to obtain a total score. References
That score is placed on the Pressure Ulcer Healing Graph. Changes in the score over Anna and Harry Borun Center for
Gerontological Research.
time provide an indication of the changing status of the ulcer. If the score decreases, The Bates-Jensen Wound Assessment
the wound is improving or healing. If the score increases, the wound is deteriorating. Tool Page. Available at:
Sussman Wound Healing Tool (SWHT) Accessed August 15, 2007.

Developed by Sussman and Swanson in 1997, this two-part tool measures pressure National Pressure Ulcer Advisory Panel.
ulcer wound healing. The focus of the tool is to track a change in tissue status and The PUSH Tool page. Available at:
wound measurement, assess whether the wound is healing and track the impact of Accessed August 15, 2007.
physical therapy technologies for wound healing.
Sussman C, Swanson G. Utility of the
sussman wound healing tool in predict-
Part I of the tool assesses 10 variables that address wound tissue attributes. The attributes ing wound healing outcomes in physical
therapy. Advances in Wound Care.
are classified as “good for healing” or “not good for healing.” The scoring system is
simply marked with a “1” if the attribute is present and “0” if the attribute is absent.

Part II evaluates wound depth and location and measures the phases of wound healing.
To obtain a copy of the Sussman Wound Healing Tool, contact Aspen Publishers, Inc.

Bates-Jensen Wound Assessment Tool

Formerly known as the Pressure Sore Status Tool (PSST)
This tool was developed by Barbara Bates-Jensen to enhance the communication
between healthcare clinicians regarding pressure ulcers. Thirteen assessment parameters
are measured on a scale of 1 to 5. Two additional parameters are measured with a
simple check system.

The tool will help Anurse track individual categories as well as an overall score. Once
the numbers are recorded and the scale is complete, a total is calculated using all
13 parameters and then placed on a linear chart. Data is collected on a routine basis,
usually weekly. The results are compared to previous assessments and treatment plans
can be adjusted accordingly.

In the movie version of her story, Alice states, “Well, I went along my merry way,
and I never stopped to reason. I should have known there’d be a price to pay,
some-day. Someday. I give myself very good advice, but I very seldom follow it.
Will I ever learn to do the things I should?”

Healthcare professionals have been publishing evidenced-based wound care research

for 40 years. If a nurse continues to practice old, ineffective treatments, she too may
find herself in trouble just like Alice.

With P4P, healthcare professionals are charged with improving patient outcomes with
efficient, effective, economical pressure ulcer care. To learn more about these wound
monitoring tools, please refer to pages 90 to 93 in the Forms & Tools section of
this magazine.

The End
Improving Quality of Care Based on CMS Guidelines 67
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Medline and MyZiva open the door to Online

Educational Opportunities...and a whole lot more

Medline, the number one provider of healthcare

supplies and equipment to the long-term care market,
and MyZiva, a leading online educational and
informational resource with more than 10,000
registered users, have joined forces to provide
enhanced educational oppor tunities to the entire
nursing home industry and a whole lot more!

As representatives of nursing homes from around the

nation can attest, MyZiva offers a broad spectrum
of education, information, tools and resources to
nursing home professionals and their staff, including
corporate compliance templates, easily retrievable
federal regulations, a searchable national nursing home
database and more.

MyZiva brings the clinical component of its educational

offerings to a new level through its relationship with
Medline. Together, they offer more than 150
courses on wound care, pressure ulcers, infection
control, incontinence, respiratory care and more.
Benefits to education subscribers include an array of
professional credits, including administrator CEs.

To learn more about the MyZiva/Medline educational

and informational initiatives, as well as its minimal
cost, visit or call

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:31 PM Page 69

Choose from any of the more than 150

online CEU-accredited courses...

Administrator Credit
Abuse and Neglect (2) ❚ Accidents and Falls (3) ❚ Administration and Management (2) ❚ Bariatrics (3)
❚ Behavior Management (3) ❚ Care Planning (2) ❚ Corporate Compliance (3) ❚ Deficiencies,
Sanctions and Appeals (2) ❚ Drug Therapy (2) ❚ Elopement and Unsafe Wandering (2) ❚ Emergency
and Disaster Preparedness (2) ❚ Employee Health and Safety (2) ❚ Ergonomics (3) ❚ Food Service (2)
❚ Hazard Communication (2) ❚ HIPAA (2) ❚ Hydration in the Long-Term Care Setting (2) ❚ Infection
Control (4) ❚ Medical Records (2) ❚ Medicare (4) ❚ Nutrition (2) ❚ Pain Management (2) ❚ Pressure Ulcers
and Skin Care (2) ❚ Public Relations and Marketing (2) ❚ Quality Assurance (2) ❚ Quality Indicators and
Quality Measures (2) ❚ Reporting Requirements (3) ❚ Resident Assessment/MDS (3) ❚ Restraints (2)
❚ Risk Management (3) ❚ Safety (2) ❚ Sexual Harassment (2) ❚ SNF Prospective Payment System
(PPS) (2) ❚ Survey Process (2) ❚ Urinary Incontinence and Use of Urinary Catheters (2) ❚ Wound Care (2)

Certified Activity Professional Credit

Behavior Management (2) ❚ HIPAA (2) ❚ Therapeutic Recreation and Activities (2)

Certified Dietary Manager Credit

Abuse and Neglect (2) ❚ Emergency and Disaster Preparedness (2) ❚ Employee Health and Safety (2)
❚ Ergonomics (2) ❚ Food Service (2) ❚ Hydration in the Long-Term Care Setting (2) ❚ Infection Control (2)
❚ Nutrition (2) ❚ OSHA (2) ❚ Purchasing and Inventor y Control (1) ❚ Quality Assurance (2) ❚ Risk
Management (2) ❚ Sexual Harassment (2)

Licensed Practical Nurse Credit

Abuse and Neglect (2) ❚ Accidents and Falls (3) ❚ Administration and Management (2) ❚ Behavior
Management (3) ❚ Care Planning (2) ❚ Constipation and Fecal Impaction (2) ❚ Corporate Compliance (3)
❚ Drug Therapy (2) ❚ Elopement and Unsafe Wandering (2) ❚ Emergency and Disaster Preparedness (2)
❚ Employee Health and Safety (2) ❚ Ergonomics (3) ❚ Hazard Communication (2) ❚ HIPAA (2) ❚
Hydration in the Long-Term Care Setting (2) ❚ Infection Control (4) ❚ Medical Records (2) ❚ Medicare (4)
❚ Nutrition (2) ❚ Pain Management (2) ❚ Pressure Ulcers and Skin Care (2) ❚ Privacy and Confidentiality (2)
❚ Quality Assurance (2) ❚ Quality Indicators and Quality Measures (2) ❚ Reporting Requirements (3)
❚ Resident Assessment/MDS (3) ❚ Restraints (2) ❚ Risk Management (3) ❚ SNF Prospective Payment
System (PPS) (2) ❚ Sur vey Process (2) ❚ Urinar y Incontinence and Use of Urinar y Catheters (2) ❚
Wound Care (2)

Registered Dietetic Technician Credit

Constipation and Fecal Impaction (2) ❚ Food Ser vice (2) ❚ HIPAA (2) ❚ Hydration in the Long-Term
Care Setting (2) ❚ Infection Control (4) ❚ Nutrition (2) ❚ Pressure Ulcers and Skin Care (2) ❚ Quality
Assurance (2) ❚ Risk Management (2)

Registered Dietitian Credit

Constipation and Fecal Impaction (2) ❚ Food Ser vice (2) ❚ HIPAA (2) ❚ Hydration in the Long-Term
Care Setting (2) ❚ Infection Control (4) ❚ Nutrition (2) ❚ Pressure Ulcers and Skin Care (2) ❚ Quality
Assurance (2) ❚ Risk Management (2)

Registered Professional Nurse Credit

Abuse and Neglect (2) ❚ Accidents and Falls (3) ❚ Administration and Management (2) ❚ Behavior
Management (3) ❚ Care Planning (2) ❚ Constipation and Fecal Impaction (2) ❚ Corporate Compliance (3)
❚ Drug Therapy (2) ❚ Elopement and Unsafe Wandering (2) ❚ Emergency and Disaster Preparedness (2)
❚ Employee Health and Safety (2) ❚ Ergonomics (3) ❚ Hazard Communication (2) ❚ HIPAA (2) ❚
Hydration in the Long-Term Care Setting (2) ❚ Infection Control (4) ❚ Medical Records (2) ❚ Medicare (4)
❚ Nutrition (2) ❚ Pain Management (2) ❚ Pressure Ulcers and Skin Care (2) ❚ Privacy and Confidentiality (2)
❚ Quality Assurance (2) ❚ Quality Indicators and Quality Measures (2) ❚ Reporting Requirements (3)
❚ Resident Assessment/MDS (3) ❚ Restraints (2) ❚ Risk Management (3) ❚ SNF Prospective Payment
System (PPS) (2) ❚ Sur vey Process (2) ❚ Urinar y Incontinence and Use of Urinar y Catheters (2) ❚
Wound Care (2)

Improving Quality of Care Based on CMS Guidelines 69

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R-E-S-P-E-C-T. This word is a familiar

mantra vocalized years ago by Aretha
Franklin and repeated by those of us in
need of just that – a little respect. As
healthcare professionals, we practice daily
respect for our patients and their given
situations. It is a normal part of our role
within that relationship. But have you
ever wondered if your professional peers
fully appreciate the presence (or absence)
of respect within professional relationships?
Too frequently battle lines are drawn
between acute, long-term care, home
care, hospice and physician’s office staff,
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Caring for Yourself

By Teresa Kellerman,

Respect means to feel or show honor

or esteem for someone or something;
each of whom has at times voiced less than kind opinions
about the care provided by their contemporaries. Sadly,
to consider the well-being of; or to
this also takes place within one’s own nursing unit and treat someone or something with
between units of the same facility. courtesy. Showing respect is a basic
law of life.
Nursing professionals have long prided themselves on
excellent patient care and, especially, on prevention of The Sacred Tree
pressure ulcers. Many of us were “raised” in a nursing
culture where a pressure ulcer is the mark of less-than-
adequate nursing care. Finger pointing and blaming for cases are etched into our minds because of the signifi-
skin breakdown or wound development has become cance of the details or the absurdity of the situation.
common behavior, often because we cannot appreciate
and respect the challenges encountered within other I received a call from a frantic nurse who had just
environments and the severity of the patient’s condi- received a 40-year-old male from an area long-term care
tion. We should honestly ask ourselves, “What care facility. She proceeded to tell me about the horrible neglect
provider does not strive for optimal outcomes for his that this man must have endured. She was certain that
or her patients?” this facility should be reported to the state authorities.
She was confident that this patient had multiple pressure
Wound care specialists, encounter wound and skin issues ulcers from poor nursing care.
on a daily basis. Many of these cases are considered to
be somewhat commonplace (skin tears, excoriation sec- Upon examination of the patient’s condition, I deter-
ondary to incontinence, etc.). For many wound, ostomy mined that his tissue injuries were not pressure ulcers;
and continence nurses (WOCN), certain scenarios and location and quality of these lesions, as well as the

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Respect for ourselves guides our

morals; respect for others guides
admitting circumstances regarding them provided valu- our manners.
able information and explained the complexity of this
scenario. With the history provided by the patient’s
Laurence Sterne
mother, it became apparent that this patient had necrotiz-
ing fascitis, a condition that nursing has no control over. the transition between care settings. This particular issue
The patient, in fact, had been admitted from a surgeon’s provides an opportunity to practice the professional
office for emergent surgery to address the rapidly pro- provision of much-needed care-related information. It
gressing necrosis. The response of this nurse, prior to acknowledges respect for the care provided by the sending
adequate patient history and examination, assumed and receiving facility and staff. National Patient Safety
that the patient’s integumentary condition was directly Goal 2E is “to implement a standardized approach to
related to his level of nursing care. ‘hand off ’ communications including an opportunity to
ask and respond to questions. [Ambulatory, Assisted
This patient was a fragile, blind diabetic with renal Living, Behavioral Health Care, Critical Access
failure. He had a previous below-the-knee amputation, Hospital, Disease-Specific Care, Home Care, Hospital,
an extremely high white blood cell count, poorly controlled Lab, Long Term Care, Office-Based Surgery].”1
blood glucose levels secondary to his infection and
severely limited sensation. The nursing staff who had Improved communication and relationships
previously taken care of him had in fact contacted the Foremost, we must practice respectful behaviors toward
patient’s primary care physician multiple times within our nursing peers. We would expect and accept nothing
the past week to report their growing concerns regarding less for ourselves, would we? As a profession, we must
his condition. Without accurate information and without assume that all caregivers practice within the same
benefit of doubt, clinicians might presume that a standard of care until proven otherwise. If we observe
patient has suffered at the hands of a caregiver. otherwise, then communication becomes even more
critical. And, when we observe firsthand that a standard
Effective communication of care has not been met, we can report true and
When critical information is not shared between care supported cases of neglect.
providers, we might fill in the blanks with inaccurate
facts, leading to faulty solutions or hostile rationaliza- Healthcare communities must develop a standardized
tion. In the previous example, no documentation from means of communication. Transfer forms need to be
the originating facility had accompanied the patient. thorough and contact information should be provided in
Nothing beyond an order set for admission was pro- the event that follow-up questions arise. You might con-
vided by the surgeon’s office. Multiple calls made to sider forming a community task force to address con-
the extended-care facility resulted in the requested docu- cerns and build a positive, open relationship with your
mentation to gain more insight into the situation. nursing colleagues.
An emotional circumstance was compounded with a
labor-intensive effort to support the patient and to Provision of appropriate information is crucial. With
prepare him for surgery later that same evening. regard to a patient’s integument and/or wound care
needs, the current treatment, skin and/or wound status
Hand-offs and related interventions for these issues should be the
Currently, one of the the Joint Commission’s national minimum data to accompany the patient. Current
patient safety goals is improvement of hand-off commu- medications and lab values, medical history and
nication. Emphasis should be placed upon the hand-off previous treatments for skin/wound needs
of patient-specific information between caregivers or will supplement the aforementioned.

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Colleagueship is the bond between BURNT LIKE TOAST?

people who share a profession … Maybe you need more R-E-S-P-E-C-T in
the workplace.
it springs from a respect of each
individual for each other and for The warning signs of no R-E-S-P-E-C-T:

themselves …
• You feel fatigued in the morning when you get up

Julie Morath
and have to face another day on the job.
• You are no longer laughing or having fun at work.
• You feel lethargic and empty on the job.
Within the Midwest community where I practice, a • You have become uncharacteristically irritable.
coalition was formed to address pressure ulcer prevention • You feel overwhelmed all the time. Even routine
involving acute, rehab, long-term, health department, tasks feel like enormous challenges to be overcome.
home and hospice care entities. A noted need and subse- • You have trouble concentrating.
quent goal of this group was to improve communication • You feel emotionally drained and "used up" at the
and care between services with regards to pressure ulcer end of the workday.
issues. Open dialogue has occurred and recognition of the • Physical problems may include sleeplessness,
need for further work has been established. But, as with chronic fatigue or loss of appetite.
any quality improvement initiative, identification of
the problem must be done. All involved parties must
The causes
acknowledge and accept responsibility for the needed
• Lack of respect among co-workers or employees
change(s). Solutions must be discovered collaboratively
and managers.
with the focus of best outcomes for patients while
• Lack of control over one's workload, schedule
maintaining respectful interaction and behaviors.
and deadlines.
• A feeling that one's ideas are not valued or listened to.
• Absence of feedback, so employees cannot see or
About the author

appreciate the results of their efforts.

Teresa Kellerman, MSN, ARNP, CNS,
CWCN, COCN, OCN, is an oncology CNS
and WOC nurse at St. Francis Health Center • Conflict between employees, or between employees
and management.
in Topeka, Kan. She is a member of many

• Anxiety about job security, or the possible

professional organizations, including Wound,
Ostomy and Continence Nurses Society
(WOCN); Oncology Nursing Society (ONS) consequences of failure at a job task or project.
and the Greater Kansas City Clinical Nurse

The remedies
Specialist Group.

• Let others know you are having difficulty and ask for
help. Be specific in your requests.
The Joint Commission. The FAQs for The Joint Commission’s
2007 National Patient Safety Goals page. Available at: • If you believe you are nearing the burnout stage, seek professional guidance and support.
Accessed August 10, 2007. • Cut back on responsibilities. If you feel the main
issue is overload of work, identify which tasks can
be eliminated or delegated to others.
• Focus on what you can control. Distinguish between
things in your personal and work life that you can
control, and those you cannot.
• Take care of yourself with a balanced diet, rest
and exercise.
• Don't take work home with you.
• Pace yourself at work. Take mini-breaks.

Reference: Galt V. New study sheds light on preventing

burnout. Globe and Mail. August 12, 2006.
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Special Features


"Why can't I get my employees

to do the things we ask them
to do?" Most healthcare organizations, regardless
of size, location or profitability, all struggle
with the same issues. One common issue is
getting employees and physicians to do
what they are supposed to do.

In our work with departmental and unit level managers, one of

the questions we get asked most often is, "Why can't I get my
employees to do the things we ask them to do?" Other versions
of this question are, "I am having trouble getting them to do (fill
in the blank), what advice do you have for me?" or, "How can
I instill a sense of personal accountability in my staff?"

Those of you that have worked with me in our Leadership

Development Institutes know that I believe in simplicity and
formulas. My motto is "Keep it simple, follow the formula!" This
concept guides my answers to managers who ask these questions.
When answering, I tell managers there are essentially only four
reasons for nonperformance. The key is to determine which of the
four reasons apply in each case and then provide the remedy for
that reason.

Reason #1: The employee does not know they are supposed to
do the job in a specific way. This is always the first question to
ask in any instance of nonperformance. I advise the manager
to go to the employee and say, "Tell me what you are supposed
to do in this situation." Note how closely their answer matches
your mental vision of what is supposed to happen in the
given situation.

Improving Quality of Care Based on CMS Guidelines 75

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In our work with management teams we often hear, sure they have received plenty of constructive training
"Everyone knows they are supposed to do this, it is to do it, and they are still not doing it, ask "Does this
just common sense." I think you will be surprised how person have the mental and/or physical capacity to
often your vision differs from that of your staff. In fact, do this job?"
the common sense you think everyone has might not
be common at all. Correcting this miscommunication The answer may be the employee does not have
will fix many of your nonperformance challenges. the capacity to do the job effectively with the amount
of training you are willing to provide to them.
Reason #2: They know what they are supposed to do, Alternatively, you might have made a hiring mistake
but do not know how to do it. This is essentially an and the person is not suited for the job you are asking
issue of training. In this circumstance, employees want them to do.
to perform, they just do not know how because they
have not been trained properly. Once you are sure Reason #4: They know what to do, how to do it and
they know what they are supposed to do, the next they have the capacity to do it, but choose (for many
question to ask is, "Am I sure they have been trained reasons) not to do it. This is willful noncompliance.
to do it the way I want them to do it?" We are always The noncompliance may stem from these
surprised at the number of institutions that add thought patterns:
instructional language to their policy and procedures • My way is better
manual and then assume that training has been done • Your way will not work
regarding application or compliance with the new • I do not want to change
requirements. Managers must give their staff the tools • I am unable to do it because
to be able to comply with the requirements of the job. of institutional obstacles
• I do not want to do it
Remember that telling is not training. Just telling • I will not be supported if I do it
an employee they should "do it this way" is not
sufficient. Effective training includes four elements: The manager must determine why the employee is
1. Explanation not performing and address the reason immediately.
2. Demonstration This response involves three components:
3. Practice 1. Provide convincing information that the
4. Reinforcement and feedback organization's way is better than the
employee's way
If what you consider training does not include 2. Provide positive rewards for good performance
these four elements, the employee has not been 3. Provide negative consequences for
trained properly. nonperformance

Reason #3: They know what they are supposed to do, Knowing and using these four reasons for nonperfor-
but do not have the physical and/or mental capacity mance have helped me tremendously during my
to perform it. In other words, no matter how much military career and in cofounding and leading two
training you give them, they are unable to do the successful businesses. Whenever I have been confronted
job. This is often the most misdiagnosed reason for with nonperformance I ask myself, "Which of the four
nonperformance. Experts estimate that up to 80 reasons is the cause?" If it is reason #1 or #2, I provide
percent of the time supervisors are incorrect when training to fix the problem. If it is reason #3, it is best
they determine this is the reason for nonperformance. to let the employee go as soon as possible. We do not
do the employee or the organization any favors by
Therefore, if you are positive the employee knows keeping them in a job they are not capable of perform-
what they are supposed to do, and you are absolutely ing. If it is reason #4, and I am unable to change the

JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:32 PM Page 77

employee’s behavior through positive rewards or

negative consequences, again it is best to let that
employee go as soon as possible.

Effective management of staff is not magic. It is

taking specific actions to obtain the behaviors from
employees that benefit the organization. It is the
things managers do that influence people's perform-
ance. If managers do not do the right things at the
right times, or in the right sequence, performance
outcomes will not be satisfactory. Use these reasons
for nonperformance to help you do the right things,
in the right sequence, to obtain the performance
you want.

Stephen W. Harden
LifeWings President
LifeWings Partners LLC was founded by a former U.S.
Navy Top Gun instructor and commercial airline pilot.
The firm specializes in applying aviation-based teamwork
training and safety tools to help healthcare facilities save
patients' lives and reduce costs. LifeWings has helped
more than 70 facilities nationwide provide better care
to their patients.

Harden SW. Sharpening the saw: a message from the president.
The Pulse. June 2007.

Improving Quality of Care Based on CMS Guidelines 77

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“ Dr. Marla”
battles breast

By Marla Shapiro, MD

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Caring for Yourself

“ I felt like my identity was

being stripped away.”
It was a routine mammogram, but when the X-ray was done, the
radiologist asked for a magnified view of my right breast. She needed to get
a better look at something.

I wasn't anxious. I knew that this was fairly routine. If the breast tissue is
dense, the X-ray film can be difficult to interpret.

But when she came back, the news wasn't good. She tried to be reassuring,
but her eyes were fixed on the floor as she suggested that I undergo
a biopsy.

I could feel the fear rising. I knew I was in trouble. After all, I was a doctor too.

But on that day, Friday, Aug. 13, 2004, without warning, I switched roles and
became a patient. It was foreign territory for me, and now, having spent 14
months there, I have to admit the journey has not been easy. The biopsy
led to surgery that ultimately confirmed I was suffering from invasive
breast cancer.

In many ways, where Dr. Marla ended and just Marla began was poorly
defined. My profession was inextricably woven into the very fabric of who
I was – someone taught to be a clear thinker and problem solver whose
decisions are based on evidence, even if it's just the best that science can
offer at the moment.

And when it comes to cancer, the evidence is staggering. According to the

National Breast Cancer Foundation, women in the United States develop
breast cancer more than any other type of cancer, except skin cancer. It
also has the second highest rate of cancer death in females. An estimated
200,000 women will be diagnosed with breast cancer this year and it will
lead to the deaths of more than 40,000 of them.

However, this disease does not only affect women. The NBCF also notes
that approximately 1,700 men are diagnosed with breast cancer each year.
It will kill roughly 450 of them.

As a doctor, you learn to respect those numbers and screen as effectively

as you can, be it clinical examination, diagnostic tests or lifestyle counseling.
As a patient, your life is changed forever. And mine has.

As well as the feelings everyone has when faced with a life-threatening

diagnosis, I had to deal with the fact that, thanks to my appearances both
on [Canadian morning news show] “Canada AM” and on [health and lifestyle
program] “Balance,” my own show, I am a public figure.

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Just what this meant was driven

home the day I went for my first
oncology appointment. As my
husband, Bobby, and I stood at
the reception desk in Toronto's
Sunnybrook Hospital, we could see
that “Balance” was playing on the
television set in the waiting room.
People behind us began to wonder
out loud if "that woman standing
there" was Doctor Marla and if
"she" had cancer.

I wanted to turn around and scream,

"I may have cancer, but I'm not deaf."
And yet I realized at the same time
that I'd have to say something about Marla – with her hair starting to grow back – and her family.
what I was going through. Keeping it
a secret was the last thing I wanted. a piece of me that was old and familiar. whether the areas where the cancer
My goal was to deliver a message: But most of my energy went into fight- had invaded my body were related to
Fight and hope. I wanted to support ing the disease. or independent of each other. As a
my family and friends with encourag- result, I was offered chemotherapy –
ing words. People ask if this fight has gone better although I could have refused
for me because I'm an informed that option.
So, when I wrote the first of my weekly patient. I really don't know. In so many
columns for The Globe and Mail's ways, it has been easier because I After that, I had to decide between
health page almost exactly a year understand the language and the radiation and mastectomy, therapies
ago, I introduced myself to readers uncertainty. But in other ways, I know that were considered equally effective
with the news of my recent diagnosis. too much and yet not enough. It is even if they are clearly so different.
very hard ever to feel reassured.
I also explained that I did not want So no one could tell me how to run
the disease to define me, but clearly it The treatment of breast cancer is the race. It's something you have to
has in many ways, some perceptible tailored to the individual and based figure out yourself: what treatments
and some not. I am not the same on where you are when you're diag- are right for you, what your comfort
woman who walked through the doors nosed. But even then, there are many level is, what risks you're willing to
of mammography that fateful day. options and no black and white, no take. It's a race I had to run alone.
right answer. As I navigated through Or so I thought.
For one thing, the treatment meant the maze of diagnosis and treatment
that I couldn't practice medicine. I options, I realized that, despite my When my husband and I told our two
did not want to abandon this role I felt knowledge, I was totally unprepared. older children, daughters Jenna and
so comfortable with – I felt like my Amanda, I minimized my concern.
identity was being stripped away. But It felt like I was running a race. There But when I was to start chemotherapy,
chemotherapy wipes out your white- are so many decisions that have to I could not shield them from the
blood-cell count and makes you a sit- be made – and made quickly. The obvious side effects I would have
ting duck for any infection; to keep various treatment options were out- to endure.
working in such a situation would lined, along with the potential benefits
have been like doing the tango in and side effects, but ultimately I had We waited a while to tell nine-year-old
a minefield. to make the choices that I hoped Matt, and thought we had done a
were right for me. good job of protecting him. But children
I forced myself to keep up with are perceptive, and he soon sensed
“Canada AM” and my other media And these choices hinged on the fact that something was wrong. Which
commitments. I needed to hold on to that my tests could not confirm frightened him because our

JBK2_HSV_v8.qxd:Layout 1 8/28/07 2:08 PM Page 81

silence suggested there was some-

thing that he could not talk about.

Once told, he was obviously relieved,

and being so young, he soon came up
with every conceivable question. He
“ I realized that, despite
my knowledge, I was
totally unprepared.”
found it curious that I would lose my
hair. (Actually, I did too.) He wanted to
know if cancer would just go away, like
a cold does. When we told him it was gradually disappearing into the side move through life, I suddenly realized
something that had to be beaten, he effects of my treatment. that they had the exact same fears.
walked around for days, boxing And while I felt I could force myself to
imaginary demons in the air. Thanksgiving last year came right after deal with anything, I could barely cope
my first round of chemotherapy, and I with their pain and fear. Try as I might,
Also, suddenly I was home a lot. My was unbelievably sick. Nothing had I could not make it go away.
children have grown up in a busy prepared me for how ill I would be. I
household with a mother who leaves felt like a toxic waste dump. I couldn't But as time went by, I found there
early and often comes home late. move, I couldn't eat. were things I could do.
And while they knew that I was always
"there for them," it wasn't always a Home from school for the weekend, The email and letters of support and
physical presence. Being there for car the girls were confronted with just how concern I received were overwhelming.
pools, events and homework often ill I had become. The fear in their eyes I am eternally grateful to the women
required a juggling act. hit me like a ton of bricks. Clearly this who came forward to share their stories.
wasn't just about me. This was their I did not have to be alone.
My newfound free time allowed me to fight too.
rediscover my kitchen. I started baking Then one day my husband asked me
and cooking so much that, after a As I tried to suppress my dark why, if one in nine of us has breast
while, the kids complained they were thoughts about not being around to cancer, does Canada not have more
gaining weight even as I was see them marry, have children and bald women running around?

The answer is that we are here but

often silent. We carry on. We wear our
wigs. We move forward as best we
can, considering so little is said about
how nothing in life prepares you to
Marla with Amanda, one
deal with a curve ball like this.
of her two daughters...

But when I was invited to go to

Vancouver to appear on “Vicki
Gabereau,” I wondered about leaving
the wig at home. The truth was that I
was wearing it only on “Canada AM.”
In real life, I walked around bald. I
gave speeches bald, went to dinner
bald. But I knew that this was different:
national television without a wig.
and with her son, Matt.

I decided that this was who I was in

real life, and so I headed off to the
West Coast wearing just my little
black hat to keep me warm.

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About the author

For years, well-known medical contributor
Dr. Marla Shapiro has waded through the
constant barrage of medical research and
has disseminated the most sensible med-
Laughing with chocolate ical information you need to make smart
breasts before her healthcare decisions. She completed
bilateral mastectomy.
medical school at McGill University and
trained at the University of Toronto for her
Master’s of Health Science in Community
Health and Epidemiology. She concluded
her specialty training in Community
Medicine receiving her Fellowship in
Community Medicine from the Royal
College of Physicians and Surgeons of
Canada. She is an Associate Professor in
As I sat in makeup and Vicki came in and honest, and the result is called
the Department of Family and Community
to say hello, she stopped and, in her Run Your Own Race.
Medicine at the University of Toronto and
typical way, said: "You look different,
is in private practice.
Mama." She smiled, I smiled and off Today, my chemotherapy is behind
we went to do the interview. me. The surgeries I elected to have
In 1993 she joined City TV in Toronto,
rather than radiation are over, and I
Ontario as the medical expert on the
She was frank and curious and asked have gone back to my office and a
nationally syndicated show “Cityline.”
tough questions. I was totally comfort- career I love.
Shortly thereafter she became the med-
able in my own skin – and totally
ical expert for “City Pulse” and CP24
unprepared for what happened next: So how have I changed? In many
News. In 2000, she left City to become
Letters came from women saying ways, I am the same – juggling a zillion
the health and medical contributor for
they had taken off their wigs after work balls and loving the return. But
CTV's “Canada AM.” In addition to her
seeing the show. in so many other ways, I am different.
weekly appearances on “Canada AM,”
The only word I can think of to
she is seen on “Newsnet” and as the
I realized then that many people had describe it is mindful. I am so much
medical consultant on CTV’s “News with
thought I was sailing through my fight more mindful of the decisions I make,
Lloyd Robertson.”
with cancer, that somehow I had the my family, my children and how I
inside track. In reality, on many levels, choose to live my life.
2003 saw the exciting addition of
it was exactly the opposite: I am no
“Balance: Television for Living Well.” Dr.
different from anyone else in the My children would say that my values
Shapiro hosted this exciting daily health
same situation. have changed, and perhaps they are
and lifestyle show. It is seen across North
wiser than their mother, who has
America and has sold internationally.
It soon became apparent to me that I finally learned to match her emotional
had a story to share – and it wasn't and her time commitments.
Dr. Shapiro is the recipient of the 2005
as much about the medicine and sci-
Media Award from the North American
entific advances as it was about the There are those who insist that I
Menopause Society for her work in
impact on my family, my life and all have inspired them with my so-called
expanding the understanding of
the things we don't talk about. courage, when, in fact, they have
menopause, and won the Society of
inspired me with their stories. It doesn't
Obstetricians and Gynaecologists of
When I spoke to CTV about making a take courage to fight when there is no
Canada/Canadian Foundation for
documentary, the network was pro- other option. I am not alone. You are
Women's Health Award for Excellence in
tective of me and said it was my deci- not alone. Together, we all make
Women's Health Journalism in 2006 for
sion, but I felt strongly that I wanted to a difference.
her documentary Run Your Own Race.
do this. A crew more or less moved in
and followed me around. My family Based on an article originally
and friends and physicians were open appearing in The Globe and Mail,
October 2005.

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Tips for Early Detection

The most important thing any woman can do to fight
breast cancer is to practice tips for early detection.
Many women are not familiar with the territory, so
here are some early detection tips, signs and symp-
toms from the National Breast Cancer Foundation,
included as reminders.

Three recommended screening methods

• Breast Self-Exam
– Studies show that regular (monthly) breast
self-exams, combined with an annual exam by
a doctor, improve the chances of detecting
cancer early.
A Must-Read • Breast Physical Exam (By a doctor)
Life in the Balance is Dr. Marla Shapiro’s – This should be done on an annual basis and
inspirational account of her battle with breast in conjunction with breast self-exams.
cancer from diagnosis to surgeries to • Mammograms
chemotherapy and her agonizing decision – The National Cancer Institute, the American
to have both breasts removed. It is also the Cancer Society and the American College of
personal story of how her family handled the Radiology now recommend annual mammograms
news and came together to achieve newfound for women over 40.
balance in their lives. This is a book for anyone
whose life has been touched by cancer or Symptoms and signs
who knows someone who has. • A new or persistent lump or a thickening in or
near the breast or possibly in the underarm area
Order your copy at one of these • A change in the size or shape of your breast
online retailers: • Discharge from either of the nipples that has not occurred before • Changes in the color or feel of your breast, areola or nipples, which might consist of
dimpling, puckering or a scaliness of the skin.

It’s critical to carry out regular breast self-examinations

– this way, you will be able to detect any of these
signs or symptoms. If you find something that
you feel is abnormal, arrange an appointment
to see your doctor.

Reference Symptoms and diagnosis.
Available at:
Accessed August 21, 2007.

Improving Quality of Care Based on CMS Guidelines 83

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BEST day
Everyone has them, but often we do not take time to reflect and learn from whatever made the day
either the best or the worst we’ve encountered. Many lessons could be learned from taking a few
minutes to sift through details and analyze data so that we can choose to either replicate or
eliminate the factors that contributed to the success or demise of a given workday.

Below are some situational examples to stimulate your mind and help you start thinking about
your own best and worst days!

“When I interview people for nursing
jobs, I’m very clear that this is not a
place of joy and happiness all the
time. Now that I’m older and I have
some experience, I feel it’s an honor
to be there at the time of death. But it
takes a piece of you every time.
Usually, I’m more happy after work
than sad. I sometimes miss the lights
and sirens, but I wouldn’t trade my
worst day here for my best day at any
other job.”

“You never know what a day will bring.

It’s strangely comforting to work in a
nursing home. There’s a rhythm to
it…the housekeepers are cleaning the
same area when you arrive each
morning, the cafeteria has chicken
strips again for lunch.”

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Caring for Yourself

“Ironically, the best day I ever spent in my eight years in hospital PR was also the worst. Our local
high school had a shooting this past spring and the victim was brought to the hospital. The entire
Communications Department, save me, was out of the office at a seminar three hours away. Being a
part-time writer, I had to step up and do interviews with national news agencies, over the phone with
NPR, etc., which was a huge learning experience. And we were the heroes, because our staff saved
this kid’s life (he was shot four times, three in the torso). But not soon after, his mom is in the paper
trashing the hospital for not covering his bills, etc. The good and the bad.
That’s working in a hospital for me.”

“Hospitals are messy places where

good and bad things happen, making
public relations a constant juggling act.
Think about it…you have a young male
motorcycle accident victim arriving in
the trauma unit who is not likely to
survive (bad) but the thought that his
organs might just bring life to many
others is the opportunity (good). Or the
hospital is planning a major expansion
of facilities to better serve its community
(good) but an unfortunate incident
happened to a patient who also
happened to be a family member

of a local businessman with lots
of money (bad).”

We want to hear
from you!
Please email stories about your
best and worst days at work
We will share many of the
responses in future issues
of Healthy Skin!

Improving Quality of Care Based on CMS Guidelines 85

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Caring for Yourself

Berries Cream & Pound Cake

Grease and flour 10-inch tube pan. Preheat oven to 325º F

8 oz. cream cheese

3 sticks margarine
3 cups sugar
1 tsp. vanilla extract
Pinch of salt
6 eggs
3 cups flour

1 large tub of whipped topping

2 packages of strawberries (sliced),
1 small package of each - blueberries,
raspberries and blackberries

Cream the first 5 ingredients together. Then add the 6 eggs

(1 at a time) and 3 cups flour. Blend. Then spoon batter
into pan. Bake 1½ hours.

Once the cake is cooled, take a knife and slice the cake into
two layers. Spread 1⁄3 of the whipped topping on the bottom
layer of cake. Top with a layer of strawberries and sprinkle with
the other berry options. Dab some additional whipped topping
on top of the berries and cap off with the top layer of the cake.
Spread the remaining whipped topping on top of the cake. Add
an additional layer of strawberries, then decorate with blueberries,
raspberries and blackberries. Cool in the refrigerator and serve.

FOLLOW THE LEADER Medline continues to

revolutionize scrubwear

• ComfortEase™: A poly-rich heavyweight

fabric that offers durability, wick-dry comfort
and a crisp look at a great price. Ciel Blue Mariner Blue
• AngelStat®: A 50/50 moderate-weight cotton/
poly blend makes these scrubs soft yet durable.
• Encore: These soft, lightweight scrubs
are both comfortable and economical. Black Caribbean Blue

Custom embroidery is available on all items!

To learn more about the complete line of Medline Seaspray Eggplant Khaki
scrubs, contact your Medline sales
representative or call 1-800-MEDLINE.

Wine Evergreen Rich Purple

Royal Midnight Blue Jade Green

Colors shown are ComfortEase™ colors. Please con-
86 HEALTHY SKIN tact you Medline rep for AngelStat® and Encore colors
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Forms & Tools

Table of Contents

Guidelines for Wound 88


Prevention of Skin Tears – 89

In-Service Outline

Bates-Jensen Wound 90
Assessment Tool

PUSH Tool 3.0 92

Quick Guide to Lab Values 94

Foley Catheter 95
Selection Guide


This section of Healthy Skin is all about making it easier for you to do your
job. It contains practical information and ideas to help you provide the best
possible care for your residents while following current guidelines and
standards of practice.

The charts, forms and systems you'll find here are intended to be used.
If you see something you like, feel free to tear it out and make it your own!

Improving Quality of Care Based on CMS Guidelines 87

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Forms & Tools

Guidelines for Wound Photography

General tips • Take the photo from the same angle each time.
• Digital photos are always preferred. It’s best to have the camera pointing perpendicular
• Grid or disposable camera shots are not to the wound instead of down from the top.
acceptable. • Taking all of the photos at the same time of the
• Need three completed case studies with a day will help with consistency in lighting.
beginning, middle and end photo. • Camera movement is the most common cause
of photo blurriness. Stand firm with your feet
Patient selection shoulder width apart and tuck your elbows tight
• Approach each resident as if their wounds will to your sides to prevent any shaking.
become a poster/case study. • Take a minimum of four shots at each visit per
• Get in the habit of using good photography wound site:
techniques every time to improve your photo > Location shot at four feet
outcomes. > Two-foot close-up – 90 percent person and
• Allow time to compose your shot and your patient. 10 percent background
> Two-foot with zoom – highlight tissue
Permission texture, drainage
Be sure to obtain a photo permit as required by your > Preview shots taken to ensure that pictures
agency or facility. are clear and visible

Frequency Additional photos of wound care procedures that high-

Photos should be taken at admission, weekly thereafter light dressing removal, amount and absorption of
and at wound closure. All efforts should be made to pro- drainage, product performance, pre- and post-irrigation
tect patient privacy with regard to HIPAA compliance. wounds and dressing application steps are all of
interest and might be useful in a poster presentation.
Preparing for your shoot
Lighting Most of us are frugal when it comes to taking photos.
Use natural light (no flash) whenever possible. Be care- Be liberal! The beauty of digital photography is that you
ful that the sun does not wash out the subject or distort can delete what you do not like. It’s better to have a lot
the surface texture. If the light source is behind you, of photos and choose the best back at the computer.
make sure your body does not create a shadow.

Your objective is to showcase the wound on a solid
background. Drape the patient in a dark blue or black
cloth, which helps to absorb the flash and decrease the
reflection off the patient’s skin. Avoid white because it
will cause many cameras to have trouble focusing.
Shiny blue underpads that reflect the flash should
also be avoided.

• Avoid clutter in the background (i.e., printed
clothing or towels).
• A ruler labeled with the date, length, width and
depth of the wound(s) must be present in
each photo.
• The resident must be positioned in the same
manner for each set of photos so that progress
can be seen.

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Forms & Tools

Prevention of Skin Tears –

In-Service Outline

Young adult skin Old skin

Effect of Aging on the Skin Prevention Strategies

Epidermal cells thin and divide slower Long sleeves
Dermis thins (overall appearance of skin is thinner) Gentle adhesives
Less collagen production (more visual wrinkling) Pillows
Elastin fiber wear (less elasticity to skin) Careful use of transfer equipment
Decrease sebum product, natural skin oils (skin is drier) Proper nutrition (internal and topical)
Decrease sweat glands (skin is drier) Appropriate hydration
Rete ridges flatten (makes skin more fragile)
Decrease number of melanocytes (“aging spots”) while Treatment Options
size of individual melanocytes increases Nonadhesive oil emulsion gauze
Decrease subcutaneous fat Hydrogel sheet
Transparent film
Risk Factors Silicone faced dressings
History of previous skin tears Wound closure strips
Compromised nutrition
Fluid volume deficit
Mobility limitations
Bruised skin
Medications that cause thinning of skin

Improving Quality of Care Based on CMS Guidelines 89

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“Reprinted with permission from Barbara Bates-Jensen

Improving Quality of Care Based on CMS Guidelines 91
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Forms & Tools

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Forms & Tools

Improving Quality of Care Based on CMS Guidelines 93

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Forms & Tools

Quick Guide to Lab Values Above normal range

• Infection
Taking a look at your residents’ lab values can tell • Non-marrow cancers
you a lot about why their wounds might not be healing • Dehydration
properly. For starters, lab values can indicate insuffi- • Inflammation
cient nutrients, oxygen and cellular components. The • Trauma, stress or hemorrhage
information below can help you evaluate lab values • Tissue necrosis
and identify health problems commonly associated
with values above and below the normal ranges.* Hemoglobin (Hb or Hgb)
Normal values
Red blood cells (RBC) • Males: 14 to 18 g/dL
Normal values • Females: 12 to 16 g/dL
• Males: 4.7 to 6.1 M/µL
• Females: 4.5 to 5.4 M/µL Hemoglobin transports oxygen and carbon dioxide.

RBCs contain hemoglobin, which allows the transport Below normal range
and exchange of oxygen and carbon dioxide to tissues. • Anemia
• Bone marrow failure
Below normal range • Cirrhosis
• Anemia • Dietary deficiency
• Lymphomas, leukemia • Hematalogic cancers
• Cirrhosis • Hemorrhage
• Dietary deficiency: iron, vitamin B12 • Prosthetic valves
• Fluid overload
• Hemorrhage Above normal range
• Normal pregnancy • Congenital heart disease
• Renal disease • Severe dehydration: severe diarrhea, burns
• Severe COPD
Above normal range
• Congenital heart disease Total protein
• Severe chronic obstructive pulmonary Normal value
disease (COPD) • 6 to 9 gm/dL
• Severe dehydration: severe diarrhea or burns
Protein is the building block of many body components,
White blood cells (WBC) including muscle, skin, hair, internal organs and blood.
Normal value
• 5.0 to 10.0 K/mm3 Below normal range
• Burns
WBCs fight infection and react against foreign bodies • Inflammatory diseases
or tissue. If the body makes poor or malformed cells, • Malnutrition
wound healing slows or halts and the wound might be • Protein-losing processes
left in a state of chronic inflammation. • Overhydration

Below normal range Above normal range

• Autoimmune disease • Dehydration
• Bone marrow failure
• Dietary deficiency: iron, vitamin B12
• Drug toxicity *List is not comprehensive.
Reference: Medline Industries, Inc. The Wound Care
Handbook. 2007

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Forms & Tools

Foley Catheter Selection Guide

The longer a resident is kept on a catheter, the higher their risk of developing a
catheter-associated urinary tract infection (CAUTI) climbs. In addition to CAUTI,
these residents are also in danger of developing other complications, such as
leakage, encrustation and blockage.

You can help reduce catheter complications and CAUTI by selecting the appropriate
catheter. Use your answers to the questions below to select the catheter that best
fits each resident’s needs.

Does patient have latex allergy or sensitivity?

Yes • Latex-free Foley catheter
• 100 percent silicone Foley catheter

No • Latex-free Foley catheters

• 100 percent silicone Foley catheters
• Coated latex Foley catheter

Does patient have history of recurrent UTI?

Yes • Latex-free Foley catheters

No • Latex-free Foley catheters

• 100 percent silicone Foley catheters
• Coated latex Foley catheters

Does patient have frequent blockage/encrustation?

Yes • Latex-free Foley catheters
• 100 percent silicone Foley catheters

No • Latex-free Foley catheters

• 100 percent silicone Foley catheters
• Coated latex Foley catheters

Is it anticipated that the patient will have the catheter

for more than ten days?
Yes • Latex-free Foley catheters
• 100 percent silicone Foley catheters

No • Latex-free Foley catheters

• 100 percent silicone Foley catheters
• Coated latex Foley catheter

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Each package is
a 2-Minute Course ™

in Advanced
Wound Care

Ta ke a lo o k
For more information regarding our Educational Packaging contact your Medline representative,
or call: 1-800-MEDLINE
©2007 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

MKT 207289/L IT 558/25M/J BK5