Primas Skin Wound Info

Gauging Pressure Ulcers:
A Nursing Home’s
Guide to Prevention
and Treatment
Gauging Pressure Ulcers: Introduction
Pressure ulcers are a significant problem across all ages and health care settings. Multiple factors put
residents at risk for developing a pressure ulcer, including immobility, chronic illness, incontinence, poor
nutrition, altered level of consciousness, altered sensory perception and a history of having pressure
ulcers.1
Pressure ulcers come at a high cost to everyone. They result in pain, suffering, diminished quality of life
and even death for some residents. For a nursing home, they represent extra staff hours and medical
supplies spent caring for a preventable condition, as well as more residents hospitalized. The cost of
treating a single full-thickness pressure ulcer can be as high as $70,000, with the total treatment cost for
pressure ulcers in the US surpassing $11 billion per year.2
Although pressure ulcers are preventable, more than one in every 10 of Missouri nursing home residents
developed a pressure ulcer in 2007. The Centers for Medicare & Medicaid Services has long focused on
helping nursing homes prevent pressure ulcers, but in 2008 they extended this effort across care settings.
Hospitals now have a payment incentive to partner with nursing homes on pressure ulcer prevention
– a good thing since 20 percent of nursing home pressure ulcers originate outside the nursing home,
generally in the acute hospital setting.
No matter where you are in your prevention efforts, now is the time to take a look at your care processes
with fresh eyes. First, review what the law says about pressure ulcers. See this toolkit’s summary of the
federal guidelines – Understanding CMS Interpretation of Tag F314. Then, use the included Pressure
Ulcer Facility Assessment Checklists to take a critical look at your current practices. Every one of these
systems is crucial to pressure ulcer prevention, so take your time completing this assessment. As you
assess, call on other staff to help you answer questions completely and honestly. Once you’ve completed
the assessment and identified key areas for improvement, review the clinical reference tools, reminder
tools and sample forms included in this toolkit. Feel free to adapt them to meet your individual needs.
1 Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006; 296: 974-984.
2 Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006;296:974-984.
Pressure Ulcers: Table of Contents
This table of contents provides an overview of the assessment and clinical reference tools for pressure
ulcers contained in this document. For further information, see the following pages for tool descriptions
organized by section. If you’re viewing this document on your computer, click on the tool name in the
table of contents below, and you will be taken directly to the resource. To download and print tools
individually, go to www.primaris.org.
I. Guidelines and Example Policies
a. Understanding CMS Interpretation of F314
b. MDS Skin Condition Coding Tip Sheet
II. Facility Assessment and Protocols
a. Facility Assessment Checklists
b. Sample Protocol
III. Resident Assessment and Monitoring Tools
a. Braden Scale
b. Skin Tear Risk Assessment
c. LTC Dehydration Risk Assessment
d. Comprehensive Admission Skin Assessment
e. Licensed Nurse Weekly Skin Assessment
f. CNA Shower Assessment
g. Daily Skin Monitoring Tool
h. Systems Investigative Audit Tool
IV. Prevention Tools
a. Pressure Ulcer Prediction, Prevention and Treatment Pathway
b. Tissue Tolerance and Individualized Turning Schedule
c. Managing Tissue Loads
d. Support Surface Characteristics and Considerations
V. Treatment Tools
a. Treatment Product Categories
b. Nutritional Wound Healing Guidelines
c. Selected Characteristics for Support Surfaces
VI. Communication Among Providers
a. SBAR Skin Care Instructions
VII. Education
a. Resident and Family Education (PUP) Brochure
b. Facility/staff education
i. Staging Guidelines from National Pressure Ulcer Advisory Panel
ii. Pressure Ulcer Classification Pocket Cards (see www.primaris.org)
iii. CNA Knowledge and Attitude Survey
Pressure Ulcers: Tool Descriptions
I. Guidelines and Example Policies
Understanding CMS Interpretation of F314: Summarizes the changes that CMS put into place with the revision of F-Tag
314. Any time you make changes, quickly review this summary to ensure that you are meeting federal guidelines.
MDS Skin Condition Coding Tip Sheet: Use this tip sheet to see, at a glance, how your coding questions might be
addressed by the RAI manual.
II. Facility Assessment and Protocols

Facility Assessment Checklists: Complete this checklist as you review your approach to pressure ulcer prevention and
treatment. It will help determine your plan’s comprehensiveness, its alignment with F-Tag 314 and good clinical practice.
Sample Protocol: Use this protocol as a guideline for establishing a comprehensive Pressure Ulcer Prevention and
Management Policy. Download the file as a separate Word document and modify it to suit your practices and materials.
III. Resident Assessment and Monitoring Tools

Braden Scale: The Braden Scale is a research-based risk assessment used widely in the nursing community. The format
allows for four separate assessments to aid in monitoring change over time.
Skin Tear Risk Assessment: Evaluating for skin tear risk and interventions is different than evaluating for pressure ulcer
risk. The skin is our first line of defense, and we must protect the skin not only from pressure ulcers but from skin tears
as well. This assessment helps determine if a resident is at risk for skin tears and offers potential interventions and a chart
review audit, encouraging staff follow-through.
LTC Dehydration Risk Assessment: Inadequate fluid intake can place residents at increased risk for pressure ulcers. This
tool will help determine resident dehydration risk, enabling staff to take a proactive approach.
Comprehensive Admission Skin Assessment: Conducting a baseline comprehensive assessment of the skin is vital. Staff
may use this form to guide them through the assessment.
Licensed Nurse Weekly Skin Assessment: All residents should have their skin assessed weekly by a licensed nurse. This
form encourages continuity in this documentation.
CNA Shower Assessment: This form recognizes the important role CNAs play in pressure ulcer prevention and empowers
them to do regular skin checks. It provides a formal method of communication to the licensed nurses of their review of
residents’ skin, which then would be followed up by the licensed staff.
Daily Skin Monitoring Tool: This tool provides a formal approach for CNAs to report areas of concern with the resident’s
skin daily. The licensed staff would then follow-up on noted areas of concern to provide a complete assessment.
Systems Investigative Audit Tool: Use this tool as a guide during a chart review to ensure all appropriate steps are being
taken for pressure ulcer prevention and management.
continued on next page >

Pressure Ulcers: Tool Descriptions
IV. Prevention Tools
Pressure Ulcer Prediction, Prevention and Treatment Pathway: This pathway assists staff in determining the appropriate
care for the individual resident. It aids in staff critical thinking skills to ensure all areas of concern are met.
Tissue Tolerance and Individualized Turning Schedule: This form can be used to document the assessment that led to
the individualized turning schedule.
Managing Tissue Loads: Use this tool to systematically choose the right mattress or wheel chair cushion, based upon a
resident’s level of need.
Support Surfaces: Characteristics and Considerations: Use this in-depth reference to learn more about the different
support surfaces available for pressure ulcer prevention or treatment.
V. Treatment Tools
Treatment Product Categories: Use this list outlining the major types of products to ensure your nursing center carries
an appropriate range of materials for pressure ulcer treatment. Nursing staff should choose the most effective dressing type
based on wound stage, characteristics and potential concerns.
Nutritional Wound Healing Guidelines: This sample procedure helps enhance pressure ulcer healing by providing
recommendations for nutritional intervention whenever possible. These are guidelines only. Individual patient and resident
needs must be taken into consideration before implementation.
Selected Characteristics for Support Surfaces: This quick visual reference compares the characteristics of the different
types of support surfaces.
VI. Communication Among Providers

SBAR Skin Care Instructions Form: Provides a standardized format for communication using the SBAR (Situation,
Background, Assessment, Recommendations) model. This form would be used in communication from wound care nurse
to unit nurse for the prevention and/or management of pressure ulcers.
VII. Education
Resident and Family Education Brochure (PUP): Use this brochure to proactively inform residents and families about
individual risk factors and prevention techniques associated with skin breakdown so they can be be involved in prevention.
Staging Guidelines (National Pressure Ulcer Advisory Panel): These are the most up-to-date guidelines for assessing the
state and the subsequent documentation of pressure ulcers.
Pressure Ulcer Classification Pocket Cards: Two double-sided reference cards were designed to assist clinical staff in
the assessment, measurement and documentation of wounds. Go to www.primaris.org to download a pdf of the cards.
Primaris partner homes may order laminated copies.
CNA Knowledge and Attitude Survey: CNAs’ participation is vital for the prevention of pressure ulcers. This survey will
assess what your CNAs know about pressure ulcers and discover areas in which they could benefit from further education.
Understanding CMS Interpretation of F314
This document summarizes key points of CMS guideline Tag F314, which state surveyors use as guidance to
help them assess nursing homes’ pressure ulcer prevention and treatment. Use this as guidance for assessing the
processes in place at your home with regard to pressure ulcer prevention, assessment, intervention, monitoring
and care planning.
Regulations: Pressure Ulcers

F314 42 CFR 483.25 (c) Pressure sores
Based on the comprehensive assessment of a resident, the facility must ensure that –
• A resident who enters the facility without pressure sores does not develop pressure sores unless the
individual’s clinical condition demonstrates that they were unavoidable; and
• A resident having pressure sores receives necessary treatment and services to promote healing, prevent
infection and prevent new sores from developing”
F314 Intent
• Promote the prevention of pressure ulcer development
• Promote healing of pressure ulcers that are present
• Prevent development of new pressure ulcers
Survey: Pressure Sore Investigative Protocol
Objective:
• To determine if the identified pressure sore(s) is avoidable or unavoidable
• To determine the adequacy of the facility’s pressure sore treatment interventions
Risk Management
• Identify and manage resident and facility risks
• Prevention of pressure ulcers benefits everyone
• Educate all staff on an ongoing basis
• Provide care based on accepted standards of practice (WOCN, AHQR, NPUAP)
• Document care based on accepted standards
• Make Care plans realistic especially when discussed with family in care plan conferences
• Watch for indicators of major system failures and initiate quality improvement activities
• Document facts, not assumptions
• Rising litigation
– What happens when the treatment sheet is not signed off?
– What happens when one lapse in weekly assessment occurs in a period where the wound declines?
– *Careful with dressings that stay on several days: What happens with weekly assess?
– Carefully consider policies on wound photography: may be “double-edge” sword
Understanding CMS Interpretation of F314: page 2
Three Key Factors for Risk Management
• Medical record must show standard of care for pressure ulcers was adhered to
• Medical record must have documentation of resident complications, risk factors, and/or underlying disease
that made the pressure ulcer unavoidable (if it is indeed)
• You must provide a comprehensive and aggressive program to prevent and treat the pressure ulcer (within
the parameters of resident advance directives)
Prevention
• What systems are in place in your facility?
– How is risk communicated to staff?
– Are there protocols for repositioning and pressure relief products that are understood by staff?
– How are you sure this is done for new admissions or those with change in status?
– Residents cannot afford to wait!
• How are moisturizers/barriers stocked?
• During “off-hours,” do staff know how to access pressure-reducing devices?
• Are tracking and assessment forms stocked?
• How are disposable briefs and underpads stocked and used?
Assessment
Avoidable vs. Unavoidable Pressure Ulcers
• Avoidable – Pressure ulcer developed and facility failed to do one or more:
▷ Defined/implemented interventions CONSISTENT with resident needs, goals
▷ Recognized standards of practice (AHCPR, AMDA, WOCN, current literature)
▷ Monitor and evaluate impact of interventions
▷ Revise interventions appropriately
• Unavoidable – Resident developed pressure ulcer although facility:
▷ Evaluated clinical condition and risk factors
▷ Defined and implemented interventions consistent with resident’s needs, goals, standards of practice
▷ Monitored and evaluated impact of interventions
▷ Revised approaches appropriately
Frequency of Risk Assessment (Braden or Norton most common)
• Minimally
▷ upon admission
▷ quarterly
▷ upon Significant Change in Condition
• Best Practice
▷ day 7, 14, 21, 28 (post-admission) then as above
▷ during acute illness
Wound Assessment
• Assessment includes a full description of the wound and peri-wound
• Measurements alone do not constitute an assessment
• Reassess weekly at a minimum
• Reassess daily if pressure ulcer is deteriorating
Staging Assessment
• Does your facility policy address your process for staging?
• Who does initial staging? How is it confirmed?
• What are you staging? All open areas or only pressure ulcers?
• Is there a facility tool for documenting staging?
Risk Assessment – Facility Wide
• Establish written guidelines, protocols, algorithms/decision trees based on risk
• Low risk does not equal no risk
• Let low scores trigger your mind clinically: don’t just treat the conglomerate of score
• Use appropriate interventions based on the risk assessment
Interventions
Address Risk Factors
• Skin care: routine inspections, cleansing, moisturizing, avoid massage
• Repositioning: 1 hour in chair by staff, 15 minutes in chair by resident; 2 hours in bed
• Pressure relief for heels
• Pressure reduction devices
• Address nutrition
• Address incontinence
• Toileting schedule? Rehab? Positioning evaluations? Incontinence products?
Combination of Prevention Interventions
• Adequate nutrition and hydration
• Repositioning schedule and positioning
• Appropriate support surfaces
• Care of skin
Monitoring Wound Status
Is It Better or Worse?
• Objectively review wound progress: measurements, type of tissue, PUSH tool
• Subjective assessments are problematic:
– “I don’t think this treatment is working. I’m calling the MD to change the treatment…”
– “The pressure ulcer is deeper than last week - of course it is worse” - not necessarily true
Monitoring Treatment Plan
• Is there a process for monitoring treatment?
• Is there a tracking tool to document response to treatment?
• Does the tracking form monitor the appropriate wound variables?
• Are there protocols for changing the treatment if it is ineffective?
• Healing - a systemic process affected by systemic conditions - treatment is more than a dressing
• When do you change the treatment?
• What determines frequency of dsg change
• How do you handle “non-traditional” recommendations or a product being used in a manner different than
its intended use?
Care Planning
• Do care plans identify risk factors?
• Are you treating the risk factors?
• Is the resident and family aware of and in agreement with goals?
• Goal must be a clear statement of intended progress and how it will be measured
• Be REALISTIC!!!!
• Determine what the goal is:
– Maintenance
– Improvement/Healing
– Comfort
– Many goals beyond healing…
▷ Resolution of periwound erythema in 2 weeks
▷ 25% reduction in amount of necrotic tissue by 1 week
▷ Decrease in intensity of pain during dressing changes from 6 to 3 (as reported by resident) by 1 week
▷ 1 cm reduction in wound dimensions by 2 weeks
Document available at www.primaris.org

MO-08-11-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare
& Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from CMS
Provider Certification, Transmittal 4, November 12, 2004; HCPro Pressure Ulcer Materials, 2004; & Pressure Ulcers F-314 by Courtney Lyder, September 2004
MDS Skin Condition Coding Tip Sheet
Definition
According the RAI Manual “A skin ulcer can be defined as a local loss of epidermis and variable levels of dermis and
subcutaneous tissue, or in the case of Stage 1 pressure ulcers, persistent area of skin redness (without a break in the skin) that
does not disappear when pressure is relieved.” (RAI Manual, pgs. 3-159)
CodingM1 - recording of all skin ulcers if caused by pressure or circulatory problems.

1. M1 - recording of all skin ulcers if caused by pressure or 4. M4 - records skin problems or lesions not caused by
circulatory problems. pressure or circulatory problems.
2. M2 - differentiates between pressure or venous stasis 5. M5 - records any specific or generic skin treatments.
ulcers only; record highest level of each. 6. M6 - records specific foot problems and care.
3. M3 - history of resolved/cured ulcers. Definition same as for M1.
Process
1. Review the record and check with appropriate nursing M4. (See pg 3-159) Record the number of skin ulcers caused
staff for the presence of any skin problems. by either pressure or circulatory problems according to
2. Examine the resident for condition (stage, number) of stage for M1. M2 is for coding the highest stage of pressure
any skin problems. Coding will be based on what is seen or venous stasis ulcers only.
(i.e. visible tissue) during the look back period. NPUAP 4. Include in M4 all skin problems not caused by pressure,
standards cannot be used for coding on the MDS. MDS venous stasis, circulatory problems or not coded anywhere
defined staging is used for M1 and M2 only. else in Section M.
3. Determine the cause of the skin ulcer. If it is caused from 5. Code all skin treatments in M5.
pressure or circulation (venous or arterial) then it is coded 6. Code all foot problems and care in M6.
in M1. All remaining skin ulcers then are documented in
Clarification
1. Necrotic eschar prohibits accurate staging. Code the skin 4. Skin ulcers should be coded in either M1, with further
ulcer with eschar as Stage 4 until debrided. clarification in M2, or in M4. Pressure or stasis ulcers
2. Good clinical practice dictates that the ulcer be re coded in M2 should not be coded in M4.
examined and re-staged after debridement. 5. If skin ulcers are captured in M1 or M4, good clinical
3. If a skin ulcer is repaired with a flap graft, it is coded as a practice would also have something documented in M5
surgical wound and not as a skin ulcer. under treatment.
6. For MDs coding, ankle problems are not considered foot
problems.
Documentation
1. For clinical practice facilities need to follow the NPUAP 2. Document weekly assessments of the wound healing
standards in regards to pressure ulcer documentation (i.e. progress or lack of. Documentation should include a
Healing stage 4 that has the appearance of tissue size and thorough description of size, drainage, etc.
depth of a stage 2- the clinical record will state a healing 3. Care planning should identify risk factors and interventions
stage 4, but the MDS would have Stage 2 in M1.) based on the identified level of risk, as well as interventions to
facilitate healing of existing skin problems.
Example
1. Mrs. B has impaired arterial circulation to her right foot. She has a Stage 3 in appearance on the top of her foot. She also has a
superficial skin tear on her right forearm. M1 would be coded as a Stage 3 ulcer, M2 would be coded with 0 (zeros) and M4a
would be checked for the skin tear. M5d, e and g may be checked, depending on specified interventions. M6c would be checked.

MO-08-47-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Pressure Ulcers: Facility Assessment Checklists
A facility system assessment is a starting point for a quality improvement project. The checklists included in
this booklet will be most useful if you take a critical look at your current practices.
Directions for Pressure Ulcers: Facility Assessment Overview Questionnaire

• To be completed by a direct care or interdisciplinary team.
• Consult with appropriate staff in answering certain questions and completing checklists.
• If you answer “No” to any of the questions below, please proceed immediately to the checklist
referenced by the page after the question.
• If you answer “Yes” to a question, the process is always complete and done so consistently. Please
continue to the next question.
• If you answer “In Progress” to any of the below questions, the need is being addressed but needs improvement.
Pressure Ulcers: Facility Assessment Yes No In Progress
Does your facility have a process to screen residents for pressure ulcer risk? (page 2)
o o o
Does your facility have a process to develop and implement care plans for residents
who have been found to be at risk or have a pressure ulcer?
(pages 3-4)
o o o
Does your facility complete a comprehensive assessment for residents who are
found to have pressure ulcers upon screening or, if there is no screening process in
place, another time? (page 5)
o o o
For residents who have pressure ulcers, does your facility have a process for
monitoring treatment and prevention? (page 6) o o o
Does your facility have a policy for pressure ulcer prevention and management?
(page 7) o o o
Does your facility have initial and ongoing education on pressure ulcer prevention
and management for all relevant staff? (page 8) o o o
When completing each checklist on the following pages:

• If you answer “Yes” to all of the questions, the process is always complete and done so consistently.
Continue to the next checklist.
• If you are not sure, or answer “No” to one of the questions, choose one or more elements on which to focus
your quality improvement.
• If you answer “Needs Improvement” to one or more of the questions, the process is not always complete
and/or not always done consistently.
Pressure Ulcers: Facility Assessment Checklists: page 2
Pressure Ulcers: Screening for Pressure Ulcer Risk

A screening assessment is a brief assessment or question that determines if the resident is at risk for pressure
ulcers. It does not include a thorough assessment of the pressure ulcer or what needs to be done if the resident is
found to have a pressure ulcer upon screening.
Does your facility’s screening process include the following components?
Needs
Yes No Improvement
Do you screen all residents for pressure ulcer risk at the following times?
Upon admission o o o
Upon readmission o o o
When change in condition o o o
With each MDS assessment o o o
If resident is not currently deemed at risk, is there a plan to rescreen at regular intervals? o o o
Do you use either the Norton or Braden pressure ulcer risk assessment tool? (If yes, STOP.
If No, please continue to next question.) Note: Federal regulations (F-314) recommend the o o o
use of standardized risk assessment tools.
If you are not using the Norton or Braden risk assessment, does your screening address the following areas?
Impaired mobility:
Bed o o o
Chair o o o
Incontinence:
Urine o o o
Stool o o o
Nutritional deficits:
Malnutrition o o o
Feeding difficulties o o o
Diagnosis of:
Diabetes mellitus o o o
Peripheral vascular disease o o o
Contractures o o o
Hx of pressure ulcers o o o
Completed by: _______________________________________ Date: ______________________________
Pressure Ulcers: Developing Care Plans

Does the resident care plan address the following interventions and risk factors (as they apply)?
Needs
Yes No Improvement
Impaired mobility
Assist with turning, rising, position o o o
Encourage ambulation o o o
Limit static sitting to 1 hour at any one time o o o
Pressure relief
Support surfaces – bed o o o
Support surfaces – chair o o o
Pressure relieving devices o o o
Repositioning o o o
Check for “bottoming out” in bed and chair (To determine if a patient has bottomed out,
the caregiver should place his or her outstretched hand, palm-up, under the mattress
overlay below the existing pressure ulcer or that part of the body at risk for pressure o o o
formation. If the caregiver can feel that the support material is less than an inch thick at
this site, the patient has bottomed out.)
Nutritional improvement
Supplements o o o
Feeding assistance o o o
Adequate fluid intake o o o
Dietician consult as needed o o o
Urinary incontinence
Cause identified and treated as appropriate o o o
Toileting plan o o o
Wet checks o o o
Treat causes o o o
Assist with hygiene o o o
Fecal incontinence
Cause identified and treated as appropriate o o o
Toileting plan o o o
Soiled checks o o o
Skin condition check
Check intactness o o o
Color o o o
Sensation o o o
Temperature o o o
continued on next page >

Pressure Ulcers: Developing Care Plans
Needs
Yes No Improvement
Treatment
Physician prescribed regimen o o o
Appropriateness to wound staging o o o
Treatment reassessment time frame o o o
Pain
Screen for pain related to ulcer o o o
Choose appropriate pain med o o o
Provide regular pain med administration o o o
Reassess effectiveness of med o o o
Assess/treat side effects o o o
Change, increase or decease pain med as needed o o o
Infection
Dressing containment o o o
Keep dressing dry/intact o o o
Assess for s/sx infection o o o
Pressure Ulcers: Assessment and Reassessment

Does your comprehensive pressure ulcer assessment include the following components?
Needs
Yes No Improvement
Do you have a tool available to document pressure ulcer assessment? o o o
Does your current assessment of pressure ulcers include:
Location o o o
Stage o o o
Size o o o
Undermining/tunneling o o o
Wound bed (tissue) o o o
Drainage/exudate o o o
Peri wound tissue (color, temp, bogginess, and fluctuation) o o o
Need for debridement o o o
Is the resident’s pressure ulcer reassessed:
Weekly o o o
Daily if worsening or high risk o o o
Does reassessment include:
Size o o o
Tunneling o o o
Sinus tracts o o o
Presence of necrotic tissue o o o
Exudate o o o
Granulation o o o
Epithelialization o o o
Color photos, diagram, or drawing o o o
Are the following related factors considered in your assessment/reassessment:
Mechanical forces (shearing, friction, pressure) o o o
Pronounced bony prominences o o o
Poor nutrition o o o
Altered cutaneous sensation o o o
Pressure Ulcers: Monitoring Treatment and Prevention

Does your facility’s process for monitoring treatment and prevention include the following?
Needs
Yes No Improvement
Does your facility use a pressure ulcer tracking tool to document treatment and healing?
(If “No,” skip to question 3.) o o o
Does the tracking form include the following:
Date o o o
Stage o o o
Current treatment o o o
Color photo, diagram, or drawing o o o
Size o o o
Depth o o o
Appearance (e.g., redness, presence of discharge, eschar formation) o o o
Does your facility have protocols to follow if current pressure ulcer treatment is
ineffective? o o o
Does your facility have protocols to follow if ulcers are found to be non-healing? o o o
Does your facility monitor pressure ulcers for the presence of infection (e.g., foul smell,
greenish drainage, cellulitis, osteomyelitis)? o o o
Is there a list of possible interventions for the resident at each level of risk (low, moderate,
or high), that nursing staff may implement to prevent pressure ulcer development? o o o
Does your facility have a protocol for management of tissue loads (e.g., positioning,
pressure relieving mattresses, dynamic mattress overlay)? o o o
Are there adequate supplies to provide preventive interventions to all residents who
require them (e.g., adequate pressure reducing or relieving mattresses/chair cushions)? o o o
Are pressure reducing or pressure relieving mattresses/chair cushions in good repair? o o o
Are pressure reducing/relieving supplies available to staff on all shifts and whenever
needed? o o o
Does your facility have protocols regarding pressure ulcer prevention that includes the
following:
Monitoring residents for incontinence o o o
Need for assistance with mobility and bed mobility o o o
Weight loss o o o
Nutritional deficiency o o o
Dehydration o o o
Pressure Ulcers: Elimination
Does the pressure ulcer elimination process include the following components?
Needs
Yes No Improvement
Does your facility’s policy include a statement regarding your facility’s commitment to
pressure ulcer prevention and management? o o o
Does your facility’s policy include screening, assessment, and monitoring of residents for
pressure ulcers? o o o
Does your facility’s policy address measures that should be taken to prevent pressure
ulcers in residents? o o o
If the resident is not currently deemed at risk, does your facility’s policy state that residents
should be screened for pressure ulcer risk at regular intervals? o o o
Does your facility’s policy state that residents who are at risk for pressure ulcers be screened at the
following times:
Upon admission o o o
Upon readmission o o o
When a change in condition occurs o o o
With each MDS assessment o o o
Does your facility’s policy state that residents at high risk for pressure ulcers should be
screened daily? o o o
Does your facility’s policy include who, how, and when pressure ulcer program effectiveness should be
monitored and evaluated?
Prompt assessment and treatment o o o
Specification of appropriate pressure ulcer risk and monitoring tools o o o
Steps to be taken to monitor treatment effectiveness o o o
Pressure ulcer treatment techniques that are consistent with clinically-based guidelines o o o
Optimize the resident’s ability to perform ADLs and participate in activities o o o
Does your facility’s policy address steps to be taken if pressure ulcer is not healing? o o o
Does your facility’s policy address a protocol for communication of reporting pressure
ulcer staging/healing to the designated MDS personnel to ensure correct coding? o o o
Pressure Ulcers: Staff Training and Education
Does your facility’s training and education program include the following components?
Needs
Yes No Improvement
Are new staff assessed for their need for education on pressure ulcer prevention and
management? o o o
Are current staff provided with ongoing education on the principles of pressure ulcer
prevention and management? o o o
Does education staff provide discipline-specific education for pressure ulcer prevention
and management? o o o
Is there a designated clinical “expert” available at the facility to answer questions from all
staff about pressure ulcer prevention and management? o o o
Is the education provided at the appropriate level for the learner (e.g., CNA vs. RN)? o o o
Does the education include staff training on documentation methods related to pressure
ulcers (e.g., location, stage, size, depth, appearance, exudate, current treatment, effect on o o o
ADL’s, pressure relieving devices used, nutritional support)?

MO-08-16-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Sample Protocol
Implement a protocol and accompanying strategies such as those below to help guide the care of
residents at risk for developing pressure ulcers.
At Risk Moderate High Risk Very High

Risk Risk
Systematic skin inspection
• • • •
Turn/reposition every 2 hours (if mobility
impaired) or more often if needed •
Turn/reposition every 2 hours and
prevent direct contact between bony • • •
prominences
Protect heels
• • • •
If bedfast, provide pressurereducing
support surface • • • •
If in wheelchair, provide pressurereducing
seat cushion • • • •
If appropriate, initiate remobilization
program (therapy if appropriate, ambulation, • • • •
standpivot transfers, restorative nursing
etc)
Manage moisture (from incontinence)
• • • •
Manage nutrition
• • • •
Reduce friction/shear
• • • •
Provide wedges/repositioning aids for 30
degree lateral positioning • • •
Supplement turning schedule with small
position shifts (hourly) • •
Obtain rehab assessment to:
Determine need for pressure relief • •
cushion
Assess correct seat height and w/c
positioning
Consider a pressure relieving support
surface or powered mattress overlay •
Written plan of care
• • • •
Staff education
• • • •
Sample Protocol: page 2
Sample risk reduction strategies:
Skin inspection: All residents should be inspected at least daily. This can be done with dressing,
undressing, toileting, bathing, pericare, etc. Pay particular attention to bony prominences.
Minimize exposure to low humidity. Moisturize dry skin.
Turning and repositioning: Keep bony prominences from direct contact using systematic turning and

repositioning and positioning devices such as pillows or foam wedges. Avoid positioning directly
on the trochanter. Determine tissue tolerance.
Wheelchair Positioning: OT evaluate for proper fit to wheelchair and appropriate pressure relieving
device. Reposition and off load eight hourly – stand if possible. Try to use at least three different
chair types daily to alter pressure points. If residents are able, teach or cue them to shift their own
weight every hour. Use a pressurereducing device such as those made of foam, gel, air or a
combination of the two. Do not use donuttype devices.
Heel Protection – Friction: To prevent friction, use “gripper” socks, sheepskin at foot of bed,
transparent dressings or skin sealants, protective dressings (such as hydrocolloids), moisturizers
Heel Protection – Pressure: Keep ALL weight off residents’ heels. Elevate lower extremities with
pillows lengthwise under lower legs, multipodus boots, heellift boots, loosen bed linens at foot
of bed, foot cradle
Manage Incontinence: Initiate bowel/bladder program or scheduled toileting, incontinent care every
two hours, incontinence barriers, briefs, absorbent underpads (made with materials that absorb
moisture & present a quick drying surface to the skin), fecal bag (if frequent stools). Avoid hot
water, and use a mild cleansing agent that minimizes irritation and dryness.
Manage Nutrition: Monitor for weight loss. Assess for chewing or swallowing problems. Provide a
combination of: dietician consults, supplements, vitamin supplements, hydration, feeding
assistance, adaptive equipment.
Reduce friction/shear: Draw sheet or lift pad for bed movement, trapeze, moisturize skin, limit head
of bed elevation to 30 degrees (and only as required), long sleeve garments/elbow protectors,
careful cleansing during incontinence/hygiene care, gait belt transfers (as appropriate), mechanical
lift.
Pressure relieving mattress/overlay: Pressure reducing mattress types include, foam, static air,
alternating air, gel or water mattresses.
Written plan of care: Each resident’s care plan should be unique, including specific turning and
repositioning plans. Indentify and address each factor noted in the Risk Assessment.
Staff Education: Target prevention at all levels of health care, from providers to residents and
families. Identify the role each plays in pressure ulcer prevention. Implement a comprehensive
pressure ulcer prevention program.
References:
Agency for Health Care Policy and Research (1994). Treatment of Pressure Ulcers. AHCPR Pub. No 950652.
University of Iowa Nursing Interventions Research Center. Prevention of Pressure Ulcers
American Medical Directors Association. Pressure Ulcers in the LongTerm Care Setting Clinical Practice Guideline. Columbia, MD: AMDA
2008
Source: QIPMO: University of MOColumbia, Sinclair School of Nursing, April 2008
MO0814PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS
Braden Scale for Predicting Pressure Sore Risk
Resident Name (Last, First, Middle) ___________________________________________________________
Room #:_________ Attending Physician:_________________________Date of Assessment: _____________
Assessment Date:
Risk Factor Score/Description 1 2 3 4
1 = Completely Limited
Sensory Perception
2 = Very Limited
Ability to respond meaningfully to pressure-
3 = Slightly Limited
related discomfort 4 = No impairment
1 = Constantly Moist
Moisture 2 = Often Moist
Degree to which skin is exposed to moisture 3 = Occasionally Moist
4 = Rarely Moist
1 = Bedfast
Activity 2 = Chairfast
Degree of physical activity 3 = Walks Occasionally
4 = Walks Freqeuently
1 = Completely Immobile
Mobility 2 = Very Limited
Ability to change and control body position 3 = Slightly Limited
4 = No Limitations
Nutrition
1 = Very Poor
Usual food intake pattern
2 = Probably Inadequate
1NPO: Nothing by mouth
3 = Adequate
2IV: Intravenously 4 = Excellent
3TPN: Total parenteral nutrition
1 = Problem
Friction and Shear 2 = Potential Problem
3 = No Apparent Problem
Total Score
High Risk: Total score ≤ 12.
Moderate Risk: Total score 13-14.
Low Risk: Total score 15-16 if under 75 years old or 15-18 if over 75 years old
For Detailed Descriptions, see page 2

Assess Date Evaluator signature/title Assess Date Evaluator signature/title
1 3
2 4
NOTE: This form is copyrighted. Permission to reproduce this form may be obtained at no charge by accessing www.bradenscale.com/copyright.asp
page 1 of 2
Braden Scale for Predicting Pressure Sore Risk: page 2
Sensory Perception Nutrition

1 = Completely Limited. Unresponsive (does not moan, flinch, 1 = Very Poor. Never eats a complete meal. Rarely eats more
or grasp) to painful stimuli, due to diminished level of than ½ of any food offered. Eats 2 servings or less of
consciousness or sedation OR limited ability to feel pain protein (meat or dairy products) per day. Takes fluids
over most of body. poorly. Does not take a liquid dietary supplement OR is
2 = Very Limited. Responds only to painful stimuli. Cannot NPO1 and/or maintained on clear liquids or IV2 for more
communicate discomfort except by moaning or than 5 days.
restlessness OR has a sensory impairment which limits the 2 = Probably Inadequate. Rarely eats a complete meal and
ability to feel pain or discomfort over ½ of body. generally eats only about ½ of any food offered. Protein
3 = Slightly Limited. Responds to verbal commands, but intake includes only 3 servings of meat or dairy products
cannot always communicate discomfort or the need to per day. Occasionally will take a dietary supplement OR
be turned OR has some sensory impairment which limits receives less than optimum amount of liquid diet or tube
ability to feel pain or discomfort in 1 or 2 extremities. feeding.
4 = No impairment. Responds to verbal commands. Has no 3 = Adequate. Eats over half of most meals. Eats a total of
sensory deficit which would limit ability to feel or voice 4 servings of protein (meat, dairy products) per day.
pain or discomfort. Occasionally will refuse a meal, but will usually take a
supplement if offered OR is on a tube feeding or TPN3
Moisture regimen, which probably meets most of nutritional needs.
1 = Constantly Moist. Skin is kept moist almost constantly by 4 = Excellent. Eats most of every meal. Never refuses a meal.
perspiration, urine, etc. Dampness is detected every time Usually eats a total of 4 or more servings of meat and dairy
patient is moved or turned. products. Occasionally eats between meals. Does not
2 = Often Moist. Skin is often, but not always moist. Linen require supplementation.
must be changed at least once a shift.
Friction and Shear
3 = Occasionally Moist. Skin is occasionally moist, requiring an
extra linen change approximately once a day. 1 = Problem. Requires moderate to maximum assistance in
moving. Complete lifting without sliding against sheets is
4 = Rarely Moist. Skin is usually dry; linen only requires
impossible. Frequently slides down in bed or chair, requiring
changing at routine intervals.
frequent repositioning with maximum assistance. Spasticity,
Activity contractures or agitation leads to almost constant friction.
1 = Bedfast. Confined to bed. 2 = Potential Problem. Moves feebly or requires minimum
2 = Chairfast. Ability to walk severely limited or nonexistent. assistance. During a move, skin probably slides to some
Cannot bear own weight and/or must be assisted into chair extent against sheets, chair, restraints, or other devices.
or wheelchair. Maintains relatively good position in chair or bed most of
the time but occasionally slides down.
3 = Walks Occasionally. Walks occasionally during day, but for
very short distances, with or without assistance. Spends 3 = No Apparent Problem. Moves in bed and in chair
majority of each shift in bed or chair. independently and has sufficient muscle strength to lift up
completely during move. Maintains good position in bed or
4 = Walks Frequently. Walks outside room at least twice a
chair at all times.
day and inside room at least once every 2 hours during
waking hours.
Mobility
1 = Completely Immobile. Does not make even slight changes
in body or extremity position without assistance.
2 = Very Limited. Makes occasional slight changes in body
or extremity position but unable to make frequent or
significant changes independently.
3 = Slightly Limited. Makes frequent though slight changes in
body or extremity position independently.
4 = No Limitations. Makes major and frequent changes in
position without assistance.

MO-08-12-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare &
Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
© Copyright Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission.
Skin Tear Risk Assessment
Resident: ___________________________________________________________ Date:_________________

This form should be completed in conjunction with the Skin Risk Assessment, in accordance with facility
policy (on admission, readmission, quarterly, and with a significant change in condition). Check “Yes” or
“No” if the item reflects the resident’s assessment. If the answer is “yes” to three or more of the items listed
below, consider implementation of the “Skin Tear Prevention Protocol.”
Skin Tear Risk Assessment Yes No Yes No

Reduced mental status o o History of syncope or unsteady gait o o
Poor nutritional status o o History of aggressive behavior o o
History of skin tears o o Resistant to care o o
Bruises easily (If yes, total number of
Dehydration o o bruises:__________) o o
Self-abusive behavior o o Skin Tear Prevention Protocol To Be
Implemented o o
Thin, translucent skin o o
Skin Tear Prevention Protocol

When the Skin Tear Risk Assessment identifies that the resident is at risk for skin tears, the nurse will review this protocol
and indicated pertinent interventions on the treatment record. The nurses on the unit, not the treatment nurse, manage
this protocol, which includes:
1. Provide covering for legs, such as long pants, heavy stockings, tube socks, or stockinet
2. Provide covering for arms, such as, stockinet, long sleeved shirts, or gowns.
3. Application of Kling for arms or legs ensuring no tape on skin.
4. Send inappropriate clothing home with the family so that it is not put on the resident by mistake. If the resident has no
family, put the clothing in storage with the resident’s name on it.
5. Re-evaluate the necessity of side rails and if still necessary pad the side rails on the bed. Care plan for potential
isolation due to the use of padded side rails.
6. Notify activities not to place the resident very close to another resident.
7. Use two staff members for all care performed as appropriate.
8. If the resident becomes combative or resists care, stop the care and return after the resident calms down. Try to identify
what triggered the behavior. Adjust the care plan as necessary to include potential interventions.
9. Provide lotion to the skin routinely.
10. Assess the resident’s overall skin condition on a weekly basis – mark completion of this task on the treatment record.
11. Maintain hydration for the resident.
12. Examine equipment (e.g. wheelchair, bed, bedrails) for sharp edges that could potentially harm the resident. Notify
maintenance if appropriate. Consult therapy in assisting with appropriate padding when necessary.
13. Notify Dietician to adjust diet as necessary.
Nurse Signature: _________________________________________ Date Protocol Initiated: __________________

Skin Tear Risk Assessment: page 2
Skin Tear Risk Assessment and Prevention Protocol—Audit
Related Federal Standard: “Quality of Care”

Audit Objectives:
To evaluate the application and use of the facility’s skin tear risk assessment.
To evaluate the application and use of the facility’s skin tear prevention protocol.
To identify that identified residents receive care based on the skin tear prevention protocol.
Resident Sample:
All residents in the facility who have received a risk assessment and residents that have been identified to be at
risk for developing skin tears.
Audit Sample Size:
_____ residents that were assessed for skin tear risk
_____ residents that were placed on the skin tear prevention protocol
Time Period of Evaluation: ________________________________________________ through: __________________
Commencement Date of Study: _____________________Expected Completion Date of Study: __________________
Criterion Instructions for

Audit Criteria Exceptions
No. Data Retrieval
The Skin Care Risk Assessment is used to assess for risk
of skin tear:
a. Upon admission Skin Care Risk
1 None
b. Upon readmission Assessment
c. Each quarter
d. With a significant change in status
The Skin Tear Risk Assessment is complete:
a. Resident name
b. Total score is indicated Skin Care Risk
2 None
c. Indication if Skin Tear Protocol is to be implemented Assessment
d. Date assessment completed
e. Nurse’s signature
If Prevention Protocol was indicated, it was implemented:
a. Interventions were identified on the protocol form
b. Interventions were placed on treatment record Residents at risk Skin Care Prevention
3
c. Interventions were identified on care plan for skin care Protocol
d. Implementation date is indicated
e. Nurse’s signature is present

Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff
Care Center.
LTC Dehydration Risk Assessment
Resident Name:____________________________________________________ Date: __________________
Check all conditions that apply to this resident. The greater the number of items checked, the greater the risk
for dehydration. Initiate a plan of care if necessary based on your findings.
Medical Conditions/History: Medications:

Diabetes
o ≥ 4 medications
o
CHF
o Diuretics
o
CVA
o Laxatives
o
Dementia
o Steroids
o
Depression
o ACE inhibitors
o
Major Psychiatric Disorder
o Psychotropics/antipsychotics
o
Renal Disease
o Antianxiolytics
o
> 4 Chronic Conditions
o Tricyclic Antidepressants or Lithium
o
History of: Intake Ability Status
o Repeated infections Swallowing difficulties
o
o Dehydration Refuses fluids
o
o Malnutrition Dislikes fluids/foods offered
o
o Constipation Fluid restriction
o
Current Status: Requires assistance to eat/drink
o
Age ≥ 85
o Poor eater (eats < 50% of each meal)
o
Female gender
o Holds food/fluid in mouth
o
Language/speech difficulties
o Drools
o
Cognitive Impairment
o Spits out food/fluid
o
o Unable to request fluids Spills fluids
o
o Unaware of thirst Tube fed
o
Recent change in mental status
o IV fluid therapy
o
Any physical immobility
o Laboratory Abnormalities:
Recent change in ability to carry out ADLs
o (or steady increase even if within normal range)
Restraints
o Urine Specific Gravity
o
Falling episodes
o Urine color dare yellow > 4
o
Urinary incontinence
o BUN/Creatinine > 20:1 -or
o
Decreased urinary output
o o  in BUN + stable Creatinine level
Constipation or diarrhea
o Serum Sodium
o
Current fever and/or infection
o Serum Osmolality
o
Vomiting
o Hematocrit > normal
o
Recent rapid weight loss (>3% / 30 days)
o BMI < 2 or > 27
o
Draining wound
o Knowledge Issues:
Lethargy/weakness
o
Lack of understanding about fluid needs
o
Increased combativeness/confusion
o
Lack of understanding about causes of dehydration
o
Readmission from > 1 day hospital stay
o
Cultural barriers about hydration, reporting thirst, end
o
Lab/Studies involving NPO or dyes
o
of life issues
Comments: _______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Nurse’s Signature:__________________________________________________________________________

MO-08-05-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do
not necessarily reflect CMS policy.
Comprehensive Admission Skin Assessment
Resident: _______________________________________________ Date:_____________________________

Perform a visual assessment of a resident’s skin upon admission. Report any areas of concern to the charge
nurse immediately. Forward any areas of concern to the next shift. Initiate a plan of care to address the
problem and alert the CNAs. Use this form to show the exact location and description of the abnormality.
Using the body chart below, describe and chart all abnormalities by number.
Indicate on the body chart any areas of concern:

A = Abrasion(s) ST = Skin Tear(s)
B = Bruise(s) SU = Stasis Ulcer(s)
PU = Pressure Ulcer(s) SW = Surgical wound(s)
S = Scar(s) O = Other
Narrative Note: Note site, length, width, depth, drainage, odor, pain and any other defining characteristics.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Nurse Signature: _______________________________________________________ Date: ____________________

Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff
Care Center.
Licensed Nurse Weekly Skin Assessment
Resident: ______________________________________________________________ Date:____________________ Room #:_________________
This form should be completed weekly on all residents per facility policy. Any areas of skin requiring treatment should have a thorough record of
documentation in addition to this form located elsewhere in the chart per facility protocol. Check “Yes” or “No” if the item reflects the resident’s
assessment. If the answer is “yes” to 3 or more of the items listed below, consider implementation of the “Skin Tear Prevention Protocol.” Review
the care plan to ensure skin care is included as necessary.
If any questions are answered “yes,” indicate location on body outline with
number of question.
Weekly Skin Assessment Yes No

Any reddened areas that remain after 30 minutes of
1 pressure reduction? Comments: __________________ o o
_____________________________________________
Any rashes? Comments: ________________________
2
_____________________________________________ o o
Any bruises? Comments:________________________
3
_____________________________________________ o o
Any open lesions, cuts, lacerations, or skin tears?
4 (Indicate even if being treated.) Comments: ________ o o
_____________________________________________
Any blisters? Comments:________________________
5
_____________________________________________ o o
Any open ulcers (indicate even if being treated.)
6 Comments: ___________________________________ o o
_____________________________________________
Excessively dry or flaky skin? Comments:___________
7
_____________________________________________ o o
Any edema? Location:__________________________
8
_____________________________________________ o o
Licensed Nurse Signature: _________________________________________________ Date: __________________

MO-08-09-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff Care Center.
Skin Monitoring: Comprehensive CNA Shower Review
Perform a visual assessment of a resident’s skin when giving the resident a shower. Report any
abnormal looking skin (as described below) to the charge nurse immediately. Forward any problems
to the DON for review. Use this form to show the exact location and description of the abnormality.
Using the body chart below, describe and graph all abnormalities by number.
Resident: _______________________________________________ Date:_______________________

Visual Assessment
1. Bruising
2. Skin tears
3. Rashes
4. Swelling
5. Dryness
6. Soft heels
7. Lesions
8. Decubitus
9. Blisters
10. Scratches
11. Abnormal color
12. Abnormal skin
13. Abnormal skin temp (h-hot/c-cold)
14. Hardened skin (orange peel texture)
15. Other: _________________________
CNA Signature:_________________________________________________________ Date: ____________________

Does the resident need his/her toenails cut?
Yes No
Charge Nurse Signature: ________________________________________________ Date: ____________________

Charge Nurse Assessment:___________________________________________________________________________
_________________________________________________________________________________________________
Intervention: ______________________________________________________________________________________
_________________________________________________________________________________________________
Forwarded to DON:
Yes No
DON Signature: ________________________________________________________ Date: ____________________

MO-06-42-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare
& Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff
Care Center.
Skin Monitoring: Daily Skin Check
Skin checks are to be completed daily for residents. A good time to do them is during AM and
PM care and during bathing time. List the resident name, type and site (as listed below) of observed
impaired skin integrity.
Diagram Key E E E H E
Types Sites
• Bruises (B) • Ears, RT or LT (E)
• Skin tears (ST) • Shoulders (S)
S S
• Pressure ulcers (PU) • Arms (A) A A A A
• Scabs (S) • Back of Head (H)
CO
• Other (O) • Coccyx (CO)
• Legs (L) HF HF
L L L L
• Shin (SH)
• Knees (K) K K
• Feet (F)
• Heels (HE) SH SH
• Hands, front (HF)
F F HE HE
• Hands, back (HB)
• Other (O)
Resident Name Type Site
Staff Name: _____________________________________________ Completion Date:___________________

MO-08-43-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare &
Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Systems Investigative Audit: Pressure Ulcer Prevention/Treatment
Purpose:
To evaluate the decision-making process and adequacy of the facility’s process in the prevention of pressure ulcers and appropriateness of treatment protocols.
• NOTE: the following audit criteria are broad. Select a current clinical practice guideline (CPG), or utilize the facility assessment tool for pressure
ulcers to guide your detailed audit.
Criteria:
1. Resident is screened within 24 hours of admission for risk of skin 6. Care plan was consistently evaluated and revised, based on current
breakdown using a standardized risk-screening tool. resident assessed needs.
2. An appropriate pressure ulcer prevention or treatment care plan was 7. Documentation of skin condition, intervention for risk factors,
put into place within the first 24 hours of admission for all residents treatment of existing pressure ulcers and evaluation of effectiveness
whether high or low risk and according to current CPGs. was timely, consistent, and follows recommended CPGs.
3. Skin/wound assessments/reassessment were done at appropriate 8. An appropriate system for communicating to all direct-care staff skin
intervals according to determined levels of risk and current CPGs, risk factors, interventions and changes in the plan of care was in place
• Full skin assessment at least weekly with detailed documentation, and functioned properly.
according to CPGs, of wound condition, if present 9. Responsibility and accountability was assigned for each phase of the
• At least daily monitor pressure sites and areas of skin changes pressure ulcer prevention/treatment process.
• Progress of wound healing is reassessed q2-4 weeks and treatment • Those designated as responsible and accountable for monitoring
plan re-evaluated if no evidence of progress noted the processes of pressure ulcer prevention/treatment carried out
4. The care plan incorporated the following care needs as well as all their responsibilities in a timely manner
identified risk factors: 10. Policy and protocols are updated and communicated to all staff
• Needs for turning/positioning were identified according to current clinical practice guidelines.
• Positioning/pressure relief product needs were identified and 11. The QA/CQI committee had processes in place to track and identify
utilized consistently and properly patterns and to determine the root cause of skin breakdown events.
• Nutrition assessment was completed and identified needs • Identified solutions were system-oriented
included in the care plan • Content of staff education was determined by competency
• Individualized skin care needs were identified and included in the evaluations and identified areas of weakness
care plan 12. If resident self-determination was a contributing factor in pressure

• Interventions were included from all disciplines for either pressure ulcer development, reasonable counsel, education and alternatives
ulcer prevention or treatment
5. Care plan interventions were implemented as indicated. were provided.
Systems Investigative Audit: Pressure Ulcer Prevention/Treatment: Page 2
Reviewer:______________________________________________ Date of review: _____________________________
Chart 1 Chart 2 Chart 3 Chart 4 Chart 5 Chart 6 Comments

1. Admission risk assessment completed with
appropriate tool
2. Skin needs care plan was in place within 24

hrs of admission
3. Assessments and reassessments done at

appropriate intervals
4. Care plan incorporates all identified risk

factors
5. Interventions are implemented as

indicated
6. Care plan shows evidence of timely

revisions based on assessed resident needs
7. Skin condition, interventions and

evaluation of interventions documented
8. Staff demonstrates awareness/

understanding of care plan content.
9. Accountability is evidenced by those

responsible for monitoring, assessment
and follow-up
10. Skin policy/protocols are current &
followed consistently
11. QA/CQI meetings focus on root-cause

analyses
12. Resident/family education provided

Pressure Ulcer Prediction, Prevention and Treatment Pathway
Step One: Assess Skin Condition
Resident is admitted or readmitted to SNF
Head-to-toe skin assessment (upon admission and weekly)
Does the resident have a pressure ulcer?

Yes No
Pressure Ulcer Documentation Overall Skin Condition Documentation

• Length • Tunneling • Color • Incisions
• Width • Necrosis • Temperature • Scars
• Depth • Granulation • Moles • Intact skin
• Location • Undermining • Bruises • Burns
• Stage • Sinus tracts
• Exudate • Pain
Report anything
Report findings
abnormal to physician
to physician
Obtain Obtain treatment

treatment order from order from physician if
physician appropriate
Notify Family Notify Family
Turn page Turn page

Go to Step 2 Go to Step 2
Remember, if a patient is at risk or has a pressure ulcer, repeat Step One on a weekly basis.

Pressure Ulcer Prediction, Prevention and Treatment Pathway
Step Two: Complete Risk Assessment to

Identify Risk Factors and Care Plan Interventions
Complete Skin Risk Assessment
At Risk? Repeat skin risk assessment at least every 90 days

Remember that those with a pressure ulcer are automatically at risk. No and significant change or per facility protocol
Yes
Does the resident have

Care Plan Actual Skin Problem Yes No Care Plan Potential Skin Problem
a pressure ulcer?
Complete Care Plan Problem Statement Complete Care Plan Problem Statement
Skin integrity, impaired, actual as evidenced by (AEB) (Wound- Potential for impaired skin integrity, as evidenced by (AEB), risk assessment indicates
specific description: Location, stage, and measurements) that the resident is at risk for skin breakdown related to (R/T) identified risk factors
related to (R/T) identified risk factors
Address Possible Risk Factors Possible Care Planning Interventions

Bed Chair
Bed/Chair • T/R schedule • Repositioning schedule
Yes • Pressure reducing/relieving device • Pressure-relieving cushion
Mobility
• Therapy consult • Assessment of chair fit
No
Friction/Shear
• Padding to prevent skin contact
Friction • Booties/heel protectors, elevate heels
and/or Yes • HOB in lowest position possible, unless contraindicated by medical condition
Shear • Positioning devices
No
Incontinence Moisture
B/B • Peri care after each incontinence • Remove incontinence brief while
Incontinence • Clean as soon as possible after soiling in bed
Yes
and • Barrier cream • Moisture barrier
Moisture • Incontinent pads, incontinent briefs
No
Nutrition and body weight
Nutrition • Weekly weight • Vitamin/medication supplements
and Body Yes • Dietician consult • Hydration
• Labs • Feeding assistance
Weight
• Food supplements • Assessment for chewing and swallowing problems
• Speech therapy
Perform Step Two at least No
every 90 days and with any Other
Other
significant change. Adjust Resident-
Yes • Add any/all interventions related to identified specific risk factors
care plan as needed. specific Risk
Factors

MO-08-52-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Tissue Tolerance and Individualized Turning Schedule
Resident: ______________________________________________________________ Date:____________________ Room #:_________________
Recommended times for change in position are noted with desired position.
Codes: RS ( right side) LS ( left side) , B (back) OOB ( lift/shift in chair) W/C, HOB ( head of bed, raised seating) T (toileted)
When repositioning check after 30 minutes to see if the bony prominence is still red. Report to nurse.
Change every hour in W/C and at least ever 2 hours in bed. Do not raise HOB higher than 30 degrees unless directed by nurse.
Date
Check back after Check back after Check back after Check back after
turned, red after 30 turned, red after 30 turned, red after 30 turned, red after 30
Actual min? Indicate “no” Actual min? Indicate “no” Actual min? Indicate “no” Actual min? Indicate “no”
Desired position or Location that is Desired position or Location that is Desired position or Location that is Desired position or Location that is
Time position & initials still red position & initials still red position & initials still red position & initials still red
11:30 pm / / / /
1:30 am / / / /
3:30 am / / / /
5:30 am / / / /
7:30 am / / / /
9:30 am / / / /
11:30 am / / / /
1:30 pm / / / /
3:30 pm / / / /
5:30 pm / / / /
7:30 pm / / / /
9:30 pm / / / /
Initial Name Initial Name Initial Name Initial Name

MO-08-13-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff Care Center.
Managing Tissue Loads
Appropriate Patient Positioning
Key
Yes Multiple Yes/No Decisions
large, truncal Stage III
or IV ulcers? Interventions
No
Able to Yes Patient at No
keep ulcer off risk for additional No special surface needed
surface? ulcers?
No Yes
Yes Skin
Use device that moves air moisture
across skin problem?
No
Multiple Yes
turning spaces Static device
available?
No
Patient
Dynamic overlay or Yes
bottoms
mattress
out?
No No
Patient
Yes Ulcer
bottoms
healing
out?
properly?
No
Yes
Ulcer
Yes
healing Monitor
properly?
No
Low air-loss bed

Yes
Ulcer
healing
properly?
No
Ulcer
healing
Air-fluidized bed properly??
No Yes
Reference: Quick Reference for Clinicians No. 15 Reevaluate plan of care Monitor
Page 10 Developed by AHCPR

Support Surfaces: Characteristics and Considerations
Specialty Beds
Air-fluidized bed (also known as a “bead bed” or “sand bed ”)

Product Characteristics: This is a bed frame containing silicone-coated beads incorporated in Gortex® covering. When air
is pumped through the beads, they behave like a liquid, creating air and fluid support. The resident “floats” on a sheet with one
third of the body above the surface and the remainder of the body immersed in the warm, dry, fluidized beads. When bed is
turned off, the surface becomes firm to allow for repositioning. Helps manage copious wound drainage or incontinence by
absorbing fluids into bed of silicone beads. Although there is some evidence that air-fluidized beds enhance pressure ulcer
healing rates, surface interface pressure remains sufficiently high to occlude capillary perfusion. Occipital and heel ulcers have
been reported to develop in patients while on an air-fluidized bed (Parish & Witkowski, 1980).
Considerations:
• Not recommended for mobile patients, patients with pulmonary disease or patients with unstable spine
• Continuous circulation of warm, dry air may dehydrate patient or desiccate wound bed
• Bed may get too hot or make room hot
• Head of bed cannot be raised; semi-Fowler’s position achieved by using foam wedges or movable sling-type device
• Coughing less effective in mobilizing secretions
• Leakage of beads may irritate the eyes and respiratory track and make floor slippery
• Width of bed may preclude care to obese patients or patients with a contracture
• Height of bed makes some nursing care difficult, and a step is needed to facilitate care
• Transfer of patient out of bed is difficult
• Bed is heavy and not easily transferable
• Some patients become disoriented or complain of feeling weightless while on surface
• Dependent drainage of catheters may be compromised because the patient is immersed in the bed
• Sharp objects may damage the surface
• Size and weight may be too large for use in home setting
• Set up and maintenance provided by company
Low air-loss bed

Product Characteristics: A bed frame with a series of connected air-filled pillows that can be calibrated for varying
amounts of pressure to provide maximum pressure reduction for residents. Dry air flow between the patient and bed
surface helps control moisture and heat buildup and prevents maceration and friction. Some models are designed to
counteract the effects of immobility on pooling of respiratory secretions and urinary stasis by providing oscillation therapy.
Other models feature kinetic therapy (rotating slowly side to side), although this is limited to a 20-degree rotation and does
not have the same effect as manually rotating the resident side-to-side.
Considerations:
• Head and foot of bed can be raised and lowered
• Transfers in and out of bed easily accomplished
• Portable motor available to maintain inflation during bed transfers.
• Motor may be noisy
• Proper inflation essential to maintain effectiveness
Support Surfaces: Characteristics and Considerations: page 2
• Bed surface is slippery; patients may slide down or out of bed with being transferred
• Heels need to be “floated” to totally relieve pressure
• Set up and maintenance provided by company
Dynamic Overlays
Alternating air-filled overlay

Product Characteristics: Air is pumped through overlay chambers at regular intervals to provide cyclical pressure
changes, creating a low-pressure and a high-pressure area. These surfaces constantly change pressure points and create
pressure gradients that enhance blood flow. Cells with larger diameter and depth produce greater pressure relief over the
body. A cell depth of not less than 3 inches is recommended.
Considerations:
• Surface is easy to clean
• Assembly required
• Sensation of inflation and deflation may bother patient
• Electricity required
• Motor may be noisy
• Excessive or sudden surface movement may disturb sleep
• Bed surface is slippery; patients may slide down or out of bed with being transferred
Static Overlays
Foam Overlay
Product Characteristics: A foam surface applied over the surface of an existing hospital mattress. The following
characteristics of foam influence the effectiveness of the overlay: base height, density and indentation load deflection (ILD).
Base height refers to the height of the foam from the base to where the foam ridges begin and should be 3 to 4 inches to
be effective in reducing pressure. Density refers to the weight per cubic foot and reflects the foam’s ability to support the
person’s weight. Foam densities of 1.3 to 1.6 pounds per cubic foot are generally effective in supporting an average size
adult. ILD is a measure of the firmness of the foam. It describes the foam’s compressibility and conformability. It also
indicates the ability of the foam to distribute the mechanical load. Measurement of ILD is expressed as the number of
pounds required to indent a sample of foam with a circular plate to a depth of 25% of the thickness of the foam. An ILD of
approximately 30 pounds is recommended. Optimal support and conformability of foam is achieved when the relationship
between 60% ILD and 25% ILD is 2.5 or greater (Krouskop & Garber, 1987; Whittemore, 1998).
Considerations:
• Plastic protective sheet is usually required for incontinent patients
• Foam may trap perspiration and be hot
• Washing removes flame-retardant coating
• One-time charge, no reoccurring charges
• No set up or maintenance fees
• Cannot be punctured by needle or metal traction
• Light weight
• Requires no maintenance
• No electricity required to operate
• May be hot and trap perspiration
• Foam has a limited life
• Lack of firm edge creates unsure surface when patient transferring on and off surface
• Must be discarded when wet from drainage or incontinence
• Adds height to the bed
Air Overlay
Product Characteristics: Interconnected bubble-like cells that are inflated with an air blower to an appropriate pressure
level. Optimum air level is defined as 1 inch or more of uncompressed support surface between bony area of the resident’s
body and the caregiver’s hand when placed under the support surface. Cells with larger diameter and depth produce
greater pressure relief over the body. A cell depth of 3 in. or greater is recommended.
Considerations:
• Easy to clean
• Low maintenance
• Repair of some products is possible
• Durable
• Can be damaged by sharp objects
• Requires regular monitoring to determine proper inflation and need for reinflation
• Adds height to bed
• Lacks a firm edge, so transfer on and off surface may be difficult
Water Overlay
Product Characteristics: A vinyl chamber that can be filled with water to appropriate level to distribute body weight
evenly over the entire supporting surface. Recommended depth is 3 in. or greater. Some models contain a baffle system to
control motion effects.
Considerations:
• Readily available in the community
• Easy to clean
• Requires water heater to maintain comfortable water temperature
• Fluid motion makes procedures difficult (e.g. positioning)
• Patient transfers may be difficult
• Inadvertent needle punctures will create leaks
• Maintenance is needed to prevent microorganism growth
• Surface is heavy
• Cannot raise head of bed unless mattress has compartments
• Can be overfilled (causing too firm a surface) or underfilled (decreasing pressure reducing benefit)
Gel Overlay
Product Characteristics: A pad constructed of Silastic, silicone or polyvinyl chloride. Lack air-flow for moisture
control and friction control is variable depending on the surface of the gel. Recommended depth for effective
support is 2 in. or more. Gel filled pads are particularly useful in wheelchairs.
Considerations:
• Low maintenance
• Easy to clean
• Multiple-patient use
• Impermeable to punctures with needles
• Surface is heavy
• Expensive purchase price
• Research on effectiveness is limited
• Some surfaces may be slippery; patient may slide down or out of bed during transfers
Replacement Mattress
Product Characteristics: Mattress made of foam and gel combinations or layers of different foam densities.
Some models have replaceable foam shapes and some have a replaceable foam core. Other replacement
mattresses contain a series of air-filled chambers covered with a foam structure. All models are covered with
a comfortable, water-repellent, bacteriostatic cover that can be maintained with routine cleaning. Mattresses
with foam should be antimicrobial and have appropriate foam ILD with high resiliency. Evidence is increasing
that replacement mattresses are superior to standard hospital mattresses and may be more effective than some
overlays (Vyhlidal, et al., 1997).
Considerations:
• Reduce use of overlay mattresses
• Reduce staff time
• Do not add height to mattress
• Provide certain level of pressure reduction automatically
• Multiple-patient use
• Easy to clean
• Use standard hospital linens
• Low maintenance
• Initial expense is high
• Some mattresses have removable sections which may be misplaced
• May not control moisture
• Potential for excessive delay in using other support surface
• No objective method for determining when or if product loses effectiveness
• Life of product is not known
Additional References:
Hess, CT: Wound care, Springhouse, Pennsylvania, 2000, Springhouse Corporation.
Krouskop TA, Garber SL: The role of technology in the prevention of pressure sores, Ostomy & Wound Management, 16:45,
1987.
Maklebust J, An Update on Horizontal Patient Support Surfaces. Ostomy & Wound Management, 45, No 1A (suppl) 70S to
77S, 1999.
Maklebust J, Sieggreen M: Pressure ulcers guidelines for prevention and management, Pennsylvania, 2001, Springhouse
Corporation.
Parish IC, Witkowski JA: Clinitron therapy and the decubitus ulcer: preliminary dermatologic studies, Dermatology,
19:517, 1980.
Vyhlidal S et al: Mattress replacement or foam overlay? A prospective study on the incidence of pressure ulcers, Applied
Nursing Research, 10(3):111, 1997.
Whittemore, R. Pressure reduction support surfaces: A review of the literature. JWOCCN, 25:6-25. 1998.
Source: National Nursing Home Improvement Collaborative Coordinated by Qualis Health, Learning Session Two,
January 2004

MO-08-48-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Pressure Ulcers: Treatment Product Categories
Pressure ulcers require consistency in treatment to promote healing. Use this list that includes the major types of products to ensure your nursing
center carries an appropriate range of materials. Nursing staff then can choose the most effective dressing type based on wound stage, characteristics
and potential concerns.
Treatment Appropriate
Products Description Wound Stage Characteristics Concerns
Polyurethane Film Adhesive and transparent. Stages 1-2 Occlusive and waterproof Should not be used with moderate to
Tegaderm™ Retains water heavy exudate wounds
Op-site◊ Impermeable to bacteria & contamination May macerate surrounding skin
EpiVIEW™ Promotes moist wound healing
others Nonabsorbent
May be changed every 3 to 7 days
May be used as a secondary dressing over a more
absorbent product
Hydrocolloid Adhesive wafers composed of gelatin, Stages 1-4 Occlusive and waterproof Should not be used with heavy exudate
DuoDERM® pectin, and carboxymethyl-cellulose Retains moisture wounds
Replicare® Impermeable Should not be used if infection is present
Comfeel® Promote moist wound healing May have odor upon removal
Others Moderately absorbent May be difficult to remove
Easy to apply
Hydrogels Glycerin or water based gels, wafers, Stages 2-4 Non-adherent May macerate surrounding tissues
Hypergel® sheets, and impregnated gauze with or Fills dead space Secondary dressing required
Carrasyn® without adhesive borders Semi-occlusive Daily application required unless applied
DuoDERM® Promotes moist wound healing with adhesive borders
Elasto-Gel Sheet™ Easy to apply & remove Dries out easily
SoloSite◊ Minimally absorbent Risk of candidiases
Others Retains moisture and rehydrates wound
Foams Hydrophilic polyurethane foam, available Stages 2-4 Non-adherent Can be used on various levels of exudate
PolyMem® in wafers, sheets, and pillow with foam Easy to apply and remove Additional fixation is required unless has
Allevyn◊ covering Highly absorbent an adhesive border
Lyofoam®
Others
Alginates Non woven fibers containing calcium Stage 2 wounds with Non-adherent Should not be used on dry or low exudate
SORBSAN™ sodium salts of alginic acid, available in a lot of exudate Promotes moist wound healing wounds, the wound may get dehydrated
KALTOSTAT® pads or ropes Stages 3-4 Can be used on infected wounds Secondary dressing required
Algisite M◊ Typically requires daily application
Others
Pressure Ulcers: Treatment Product Categories, Page 2
Treatment Appropriate
Products Description Wound Stage Characteristics Concerns
Antimicrobial Ionic silver and cadexomer iodine that Stage 2 wounds Manages bacterial burden Do not use with a resident with a known
ACTICOAT◊ provides sustained antimicrobial barrier to when antimicrobial Non-cytotoxic sensitivity to silver.
SilvaSorb® multiple bacteria including strains of MRSA treatment is needed Iodine products should be avoided if
IODOSORB◊ and VRE. Can be found in different types Stages 3-4 known sensitivity, or thyroid disorder.
ALLEVYN Ag◊ of products including alginates, gels and Do not use in conjunction with topical
Optifoam AG® polyurethane film antibiotics
Others
Collagen Collagen provides the matrix for the body’s Wounds that have Promotes new tissue growth Do not use on dry wounds
Biostep◊ tissue structure. Stimulates wound healing stalled in healing Wound debridement Do not use with patients sensitive to
Prisma® Can be found in different delivery systems: Chronic wounds Pulls wound edges together bovine products
Promogran® dried collagen matrix, hydrogel with
Puracol® collagen, hydrogel base.
Others
Gauze, Dry or Wet Woven natural cotton fibers,; non woven Stages 2-4, especially May be dampened with saline or water Moist to dry debridement can be painful,
rayon and plastic blends; available in pads if wound is deep or Inexpensive damaging healthy tissue
and rolls, sterile and non sterile has tissue that needs Facilitates moist to dry debridement Woven gauze is abrasive
debridement Non-adherent when used as a wet to moist dressing Requires frequent changes
Minimal to moderate absorbency Packing may harden, causing further
pressure injury
Related Wound Treatments

Treatment
Products Description Indications Contraindications Concerns/Precuations
Vacuum Controlled System that uses controlled negative Pressure ulcers Malignancy Active bleeding
Assisted Closure pressure to help promote wound healing. Traumatic wounds Untreated osteomyelitis Difficult hemostasis
(V.A.C.) VAC system pulls infectious materials and Post op-dehisced & Unexplored fistulas into the body cavity or to an organ Anticoagulant therapy
KCI VAC® excess interstitial fluid from the wound surgical wounds Necrotic tissue with eschar in the wound abed
Engenex™ Exposed arteries or veins
EZCARE◊ Uncontrolled pain
V1STA◊
** Brands are listed for reference purposes only. We do not recommend use of one brand over another.

MO-08-45-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services, and adapted from LHCR. The contents presented do not necessarily reflect CMS policy.
Nutritional Wound Healing Guidelines
Policy:
This sample procedure is to help enhance the healing of pressure ulcers by the use of nutritional intervention
whenever possible. These are guidelines only and individual patient and resident needs must be taken into
consideration before implementation.
Procedure:
• The nursing department reports all pressure ulcers and their stage to food and nutrition services.
• The available dietician is contacted and reviews each case to make an individualized nutrition care plan.
• Food and nutrition services may implement the following interventions, based upon the stage of resident’s
pressure ulcers. Note that vitamin and mineral supplementation would require a physician’s order.
» Stage 1: 4 Vitamin C-rich food, high protein afternoon snack and a daily MVI with minerals
» Stage 2: Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day and MVI with
minerals daily
» Stage 3: 8 oz. Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day, high-protein
snacks twice a day and MVI with minterals
» Stage 4: 8 oz. Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day, high-protein
snacks three times a day and MVI with minerals
Other nutritional considerations:
• Think about other options to enhance nutritional status, such as:
» Increase eggs, milk, meat and cheese for additional HBV protein
» Add protein powder to foods
» Add other foods high in Vitamin C if the resident or patient dislikes orange juice
» Use Arginaid powder in place of Arginaid Extra if the patient is obese
• Continue nutritional interventions until wound has been healed for two weeks
• Avoid zinc supplementation for more than two months at a time
• Goal caloric intake is 30-35 kcal per kg or BMR x 1.5 stress factor x 1.2 (bed) or 1.3 (out of bed)
• Goal protein intake with no renal considerations is as follows:
» Stage 1: 1.2-1.4 g. per kg.
» Stage 2: 1.4-1.6 g. per kg.
» Stage 3: 1.6-1.8 g. per kg.
» Stage 4: 1.8-2 g. per kg.
• Goal of fluid is 30-35 ml. fluid per kg.
• If on chronic antibiotic use, give yogurt or lactobacillus supplements
• If patient/resident has a compromised gut (intestinal mucosal atrophy or malabsorbtion from malnutrition,
10-20 mg. of glutamine supplementation should be considered
Note: 8 oz. Arginaid Extra provides the following: 10 g. protein, 250 calories, 20 mg. zinc, 1,000 IU vitamin A, 250 mg. vitamin C; MVI with minerals usually contain
the following amounts: 15 mg. zinc, 3,500 IU vitamin A, 60 mg. vitamin C, 18 mg. iron and 2 mg. copper

Selected Characteristics of Support Surfaces
Selected Characteristics for Classes of Support Surfaces

Support Devices
Alternating Static Flotation Standard
Performance characteristics Air-fluidized Low Air-loss Air (air or water) Foam Mattress
Increased support area Yes Yes Yes Yes Yes No
Low moisture retention Yes Yes No No No No
Reduced heat accumulation Yes Yes No No No No
Shear reduction Yes ? Yes Yes No No
Pressure reduction Yes Yes Yes Yes Yes No
Dynamic Yes Yes Yes No No No
Cost per day High High Moderate Low Low Low
Reference: Quick Reference Guide for Clinicians, No. 15, page 11. Developed by the Agency for Healthcare Research and Quality (AHRQ).
Chair Support Surfaces

Support Surface Characteristics Cost Concerns
Foam Cushion • Provides some pressure reduction, Low Cost • After laundering, this surface is no longer
depending upon the thickness of the useful for pressure reduction. A slip cover
foam (a thickness of no less than four that can be separately laundered keeps
inches is recommended) the cushion clean and dry
• Resident still requires repositioning at
least every hour
Gel Cushion • Reduces pressure by spreading pressure Low to • Pressure reduction depends on the
across the contact surface Moderate cushion’s condition (watch for breaks
• Does not replace repositioning Cost in the integrity of the cushion, which
renders this product ineffective)
• Do not attempt to mend any breaks in
the cushion
Air-filled Cushion • Reduces pressure by evenly distributing High Cost • Compromised integrity can render this
weight product ineffective. An ineffective air-
• Cells fill with air and deflate as pressure is filled cushion should be replaced
applied. Does not replace repositioning

SBAR: Skin Care Instructions
S
Situation
Resident Name: ______________________________________________________ Age:___________ Admit Date: _________________
Admitting physician/consulting physician: ___________________________________________________________________________
Diagnosis/reason for admission: ____________________________________________________________________________________
Treatment plan: _________________________________________________________________________________________________
B
Background (check all that apply)
Past medical history: _____________________________________________________________________________________________
Allergies: _______________________________________________________________________________________________________
Diet type: ___________________________________________ q NG/G-tube feedings q TPN/PPN q Ostomy/drains q Foley
Medication Medication
A
Assessment (check all that apply)
q Pressure ulcer present q Precautions:___________ q Completely immobile q Limited mobility q Fully mobile
q Incontinent q Impaired sensation q Alert/oriented q Confused q Lethargic/unresponsive q Photos taken
Braden Score:_______ Decubitus Key Site Diagram
q High Risk Stage I: Red/skin intact Front Back
q Low Risk Stage II: Superficial breakdown
q No Risk Stage III: Skin breakdown Sub Q involved
Stage IV: Skin breakdown. Muscle/bone exposed
Right Left Left Right
*Do no stage if base of wound not visible
Date Site # Stage Size (in cm) Description (color, drainage, odor, sloughing, eschar, undermining)
R
Recommendation (check all that apply)
Pressure Ulcer Prevention Measures Pressure Ulcer Management
q Keep clean and dry q Avoid diaper/brief use q Ulcer treatment: _____________________________________
q Apply cleanser/barrier lotions to ________ every ____ hours q Dressings (specify type and frequency): __________________
q Apply Nystatin powder to _____________ every ____ hours ___________________________________________________
q Use special bed/mattress (specify type): __________________ q Wound vac: _________________________________________
q Turn and reposition patient every ______ hours q Consider Foley catheter:_______________________________
q Use chair cushion (specify type): ________________________ q Odor control:________________________________________
q Elevate heels q Use heel protectors/heel lift q Dietary/nutrition consult
q Use elbow protectors q Dietary/nutrition consult q Other:______________________________________________
q Other:______________________________________________ ___________________________________________________
Comments: _____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Assessment and recommendations completed by (signature)__________________________________ Date: __________________
Treatment protocol approved by (signature) ________________________________________________ Date: __________________

What happens if I get a pressure ulcer?
P
Pressure ulcers are serious problems that can lead to
pain, slower recovery from health problems and possible
complications such as infection. By working with your health ressure
U
care team to lower your risk factors, most pressure ulcers can
be prevented.
lcer
Ask your health care
provider if you are at risk P revention
for pressure ulcers, and
work together to develop a
plan to prevent them.
PUP
protects your
skin
MO-08-44-PU June 2008 This material was prepared by Primaris, a Medicare Quality Improvement Organization, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The
contents presented do not necessarily reflect CMS policy.
Reduce your risk of getting pressure ulcers. Get your family and health care team involved in prevention.
What is a pressure ulcer? A pressure ulcer, also known Who gets pressure ulcers? Anyone confined to a bed
as a pressure or bed sore, is an area of the skin that has damage or chair, who is unable to move, has loss of sensation, bowel
caused by unrelieved pressure. Pressure ulcers begin as reddened or bladder control, poor nutrition or has lowered mental
areas but can damage skin and muscles if not treated properly. awareness is at risk of getting a pressure ulcer.
Where are they found on the body? Pressure ulcers What can I do to prevent pressure ulcers?
typically occur in bony areas of the body that sustain pressure • Keep moving and change your position frequently. If you
when lying or sitting in bed for long periods of time (shoulders, are unable to move yourself, make sure the staff helps you
elbows, hips, buttocks and heels). reposition regularly.
• Look after your skin. Keep skin and bedding dry and
moisturize dry skin.
• Look for skin’s warning signs. Let the staff know if your
skin stays red longer than thirty minutes, feels warm or
firm to the touch and/or is blistered or broken.
• Reduce friction. Don’t pull or drag yourself across
sheets or push or pull with your heels. Avoid repetitive
movements, such as scratching your foot on the sheets.
• Eat a balanced diet. Ask your nurse or health care
professional for a proper nutritional plan.
Stages
Pressure Ulcer Definition and Stages
D E F I N ITI O N P R E S S U R E U LC E R STAG E S
A pressure ulcer is localized (SUSPECTED) DEEP TISSUE INJURY STAGE III
injury to the skin and/or Purple or maroon localized area of discolored intact Full thickness tissue loss. Subcutaneous fat may be vis
skin or blood-filled blister due to damage of underlying ible but bone, tendon or muscle are not exposed.
underlying tissue usually soft tissue from pressure and/or shear. The area may Slough may be present but does not obscure the depth
be preceded by tissue that is painful, firm, mushy, of tissue loss. May include undermining and tunneling.
over a bony prominence, boggy, warmer or cooler as compared to adjacent tis
Further Description: The depth of a stage III pres
as a result of pressure, or sue.
sure ulcer varies by anatomical location. The bridge of
Further Description: Deep tissue injury may be diffi the nose, ear, occiput and malleolus do not have sub
pressure in combination cult to detect in individuals with dark skin tones. cutaneous tissue and stage III ulcers can be shallow. In
with shear and/or friction. Evolution may include a thin blister over a dark wound contrast, areas of significant adiposity can develop
bed. The wound may further evolve and become cov extremely deep stage III pressure ulcers. Bone/tendon
A number of contributing ered by thin eschar. Evolution may be rapid exposing is not visible or directly palpable.
additional layers of tissue even with optimal treatment.
or confounding factors are STAGE IV
STAGE I
also associated with pressure Full thickness tissue loss with exposed bone, tendon or
Intact skin with non-blanchable redness of a localized muscle. Slough or eschar may be present on some
ulcers; the significance area usually over a bony prominence. Darkly pig parts of the wound bed. Often include undermining
mented skin may not have visible blanching; its color and tunneling.
of these factors is yet may differ from the surrounding area.
Further Description: The depth of a stage IV pres
to be elucidated. Further Description: The area may be painful, firm, sure ulcer varies by anatomical location. The bridge of
soft, warmer or cooler as compared to adjacent tissue. the nose, ear, occiput and malleolus do not have sub
Pressure ulcers are staged Stage I may be difficult to detect in individuals with dark cutaneous tissue and these ulcers can be shallow. Stage
skin tones. May indicate “at risk” persons (a heralding IV ulcers can extend into muscle and/or supporting
using the system at right. sign of risk). structures (e.g., fascia, tendon or joint capsule) making
osteomyelitis possible. Exposed bone/tendon is visible
STAGE II or directly palpable.
Partial thickness loss of dermis presenting as a shallow
open ulcer with a red pink wound bed, without slough.
UNSTAGEABLE
May also present as an intact or open/ruptured serum- Full thickness tissue loss in which the base of the ulcer
filled blister. is covered by slough (yellow, tan, gray, green or
brown) and/or eschar (tan, brown or black) in the
Further Description: Presents as a shiny or dry shal
wound bed.
low ulcer without slough or bruising.* This stage
should not be used to describe skin tears, tape burns, Further Description: Until enough slough and/or
perineal dermatitis, maceration or excoriation. eschar is removed to expose the base of the wound,
the true depth, and therefore stage, cannot be deter
*Bruising indicated suspected deep tissue injury.
mined. Stable (dry, adherent, intact without erythema
National Pressure Ulcer Advisory Panel
1255 Twenty-Third Street NW, Suite 200 or fluctuance) eschar on the heels serves as “the
Washington, DC 20037 body’s natural (biological) cover” and should not be
T: 202-521-6789 removed.
F: 202-833-3636
www.npuap.org
This staging system should be used only to describe pressure ulcers. Wounds from other causes, such as
arterial, venous, diabetic foot, skin tears, tape burns, perineal dermatitis, maceration or excoriation should not be
staged using this system. Other staging systems exist for some of these conditions and should be used instead. Updated 02/2007 Copyright © 2007
Pressure Ulcer Classifications
Suspected Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood-filled
blister due to damage of underlying soft tissue from pressure and/or shear.
The area may be preceded by tissue that is painful, firm, mushy, boggy,
warmer or cooler as compared to adjacent tissue.
Further description
Deep tissue injury may be difficult to detect in individuals with dark skin
tones. Evolution may include a thin blister over a dark wound bed. The wound
may further evolve and become covered by thin eschar. Evolution may be
rapid exposing additional layers of tissue, even with optimal treatment.
Stage 1
Intact skin with non-blanchable redness of a
localized area usually over a bony prominence.
Darkly pigmented skin may not have visible
blanching; its color may differ from the
surrounding area.
Further description
The area may be painful, firm, soft, warmer or
cooler as compared to adjacent tissue. Stage I may
be difficult to detect in individuals with dark skin
tones. May indicate “at risk” persons (a heralding
sign of risk).
Stage II
Partial thickness loss of dermis presenting as a
shallow open ulcer with a red pink wound bed,
without slough. May also present as an intact or
open/ruptured serum-filled blister.
Further description
Presents as a shiny or dry shallow ulcer without
slough or bruising.* This stage should not be
used to describe skin tears, tape burns, perineal
dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury
Pressure Ulcer Classifications
Stage III
Full thickness tissue loss. Subcutaneous fat may
be visible but bone, tendon or muscle are not
exposed. Slough may be present but does not
obscure the depth of tissue loss. May include
undermining and tunneling.
Further description
The depth of a stage III pressure ulcer varies by
anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have subcutaneous
tissue, and stage III ulcers can be shallow. In
contrast, areas of significant adiposity can develop
extremely deep stage III pressure ulcers. Bone/
tendon is not visible or directly palpable.
Stage IV
Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be
present on some parts of the wound bed. Often
include undermining and tunneling.
Further description
The depth of a stage IV pressure ulcer varies by
anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have subcutaneous
tissue and these ulcers can be shallow. Stage IV
ulcers can extend into muscle and/or supporting
structures (e.g., fascia, tendon or joint capsule)
making osteomyelitis possible. Exposed bone/
tendon is visible or directly palpable.
Unstageable
Full thickness tissue loss in which the base of the ulcer is covered by slough
(yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the
wound bed.
Source: National Pressure Ulcer Advisory Panel, Pressure Ulcer Stages Revised, February 2007.
Permission to use granted to Primaris, the Quality Improvement Organization for Missouri.
Documentation and Measuring
Measuring Wounds
15
Measure the length “head to toe” at the longest point (A) and the
width at the widest point (B). Measure the depth (C) at the deepest
point of the wound. All measures should be in centimeters.
14
This ruler is intended for use as a reference only. To prevent infection, do not use this ruler to measure an actual wound.
A
13
B
12
11
Using a clock format, describe the location and extent of
tunneling (sinus tract) and/or undermining.
10
12
sample
9 3
8
6
7
The head of the patient is 12:00, the patient’s foot is 6:00

6
Tunneling/Sinus Tract Undermining

A narrow channel of Tunneling wound which
passageway extending into begins directly under the
5
healthy tissue wound edge.

4
3
2
If the wound has many landmarks, you may want to trace it

before measuring.
1
CM
Pressure ulcer documentation includes
Wound location Pain

Stage Exudate/Drainage
Size • Amount
• Length • Color
• Width • Odor
• Depth Description of
Tunneling/Sinus Tract Surrounding Tissue
Undermining Support Surface
Necrotic Tissue Wound edges
• Slough • Round
• Eschar • Rolled
• Extended
Granulation
Note the following skin characteristics

• Color • Incisions
• Temperature • Scars
• Moles • Intact
• Bruises • Burns
MO-08-49-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for
Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services, and adapted from LHCR. The contents presented do not necessarily reflect CMS policy.
Pressure Ulcers: CNA Knowledge & Attitude Survey
We are interested in your individual answer. Please check the box to indicate “True” or “False” for each of the
following statements.
Position Title: _____________________________________________________________________________
Department: _______________________________Shift (check one): o Days o Evenings o Nights
Pressure Ulcers: CNA Knowledge and Attitude Survey True False

1. Identification and reporting of reddened or open areas of skin are part of my job. o o
2. Pressure ulcer prevention is part of my job. o o
3. Pressure ulcers should only be documented by RN or LPN staff members. o o
4. Immobility is a cause of pressure ulcers. o o
5. Incontinence is a cause of pressure ulcers. o o
6. Poor dietary intake is a cause of pressure ulcers. o o
7. Chronic illness is a cause of pressure ulcers. o o
8. Poor circulation is a cause of pressure ulcers. o o
9. Pressure ulcers are part of the aging process. o o
10. Pressure ulcers can be prevented by proper positioning of residents. o o
Pressure ulcers begin with a reddened area of the skin that does not disappear
11.
after pressure is relieved. o o
Residents who have had a pressure ulcer in the past are more likely to develop
12.
one in the future. o o
13. A bed ridden resident will not fully recover from a pressure ulcer without surgery. o o
Pressure ulcers are often viewed as a sign of poor care being provided by the
14.
nursing staff. o o
15. Pressure ulcers lower a resident’s self-esteem. o o
16. Pressure ulcers can occur on any area of the body. o o
Pressure Ulcers: CNA Knowledge & Attitude Survey, page 2
CNA Knowledge and Attitude Survey Results

A Guide to Action
Ask staff to complete the CNA Pressure Ulcer Knowledge and Attitude Survey. Then, use the following as an
answer key and a guide to action. You’ll notice that particular answers may be “True” for some staff and “False”
for others. This sheet will show how you might revise overall nursing home practices to improve staff knowledge
and residents’ care.
Questions 1 & 2
All nursing home clinical staff should have identification, assessment, prevention, care and documentation of
pressure ulcers identified as a part of their job duties. If your staff felt this statement was “False,” this may be an
area you could focus on for additional training.
Non-clinical staff’s answers may vary between “True” and “False.” If you have non–clinical staff who feel that
prevention is not part of their job, consider additional training. It is important for all staff to recognize ways
they can identify potential problems and inform appropriate clinical staff. Ideas for improvement:
• Explain how and why you’re committed to pressure ulcer prevention and treatment
• Describe you home’s overall pressure ulcer plan
• Describe each team member and family member’s role in pressure ulcer prevention assessment and treatment
Question 3
This question addresses pressure ulcer documentation. All staff is responsible for noting information as a
part of the general pressure ulcer plan of care. Leaders must instruct how and where that information will be
documented on the resident’s record. Non-clinical staff may answer “False,” but you need a process for non-
clinicians to report their observations as well, ensuring this information is documented. Ideas for improvement:
• Define pressure ulcer documentation guidelines for all disciplines.
• Offer training on sharing work responsibilities among disciplines. For example, activities staff must
reposition resident while attending activities and document this for staff sharing, dietary staff must know the
resident with a pressure ulcer cannot sit up to eat
• Identify pressure ulcer tools to increase documentation consistency throughout the facility and within
clinical staff. For example: ulcer measurement guide, bedside turning schedule, staging guidelines or exudate
documentation
Questions 4, 5, 6, 7, 8 and 12
These question reference risk factors for pressure ulcer formation. Immobility, poor nutrition, incontinence and
circulatory conditions are all risk factors.
If your facility’s surveyed staff felt any of these statements were “False,” it may indicate that the pressure ulcer
risk factors are not well known or their importance is not well understood. You may want to identify if one
group of employees or employees in general need information regarding risk factors and the role they play in
pressure ulcer formation. Questions to ask staff:
• What are the identified pressure ulcer risk factors?
• How do risk factors contribute to the formation of pressure ulcers?
• When are residents assessed for risk factors in your facility?
• What effect do risk factors have on residents’ plan of care?
• Who is responsible for identification and care planning for residents with identified risk factors?
• Why is this important?
Question 9
This question addresses a common misconception. Pressure ulcers are not part of the normal aging process.
Although loss of skin elasticity and thinning of the skin are normal with aging, pressure ulcer formation is not.
If most of your staff answered “True” to this survey question, you need to provide them with information about
the normal aging process, including:
• How the factors of the normal aging process contribute to the risk for pressure ulcer formation.
• What your facility is doing to address the care associated with the elderly. For example, nutritional and
activity programs, support groups, association with community support group.
• Your facility’s efforts to communicate with other health care facilities that you have direct interaction with,
i.e. referring hospitals, senior citizen groups, physician’s offices, home health agencies.
Question 10
This question addresses the role of proper positioning in pressure ulcer prevention. If the lower extremity
were positioned with proper support to keep pressure off the heel, an ulcer due to pressure on the heel would be
prevented.
If staff felt positioning did not contribute to pressure ulcer prevention, as noted with a “False” answer, consider:
• Instruction on and demonstration of basic positioning techniques.
• Reviewing your home’s resident care plans to address proper positioning and repositioning, i.e. turning
schedule, pressure reduction techniques, devices available at your facility to reduce pressure load.
• Reviewing of the etiology of pressure ulcer formation with staff, such as prolonged pressure reducing the
blood flow to the capillaries causing tissue damage.
Question 11
This question addresses pressure ulcer development. Pressure ulcers begin with a reddened area of the skin
that does not disappear after the pressure is relieved. This is identified as a Stage I pressure ulcer. A response
of “False” to this question indicates your staff doesn’t have a good understanding of pressure ulcer formation.
Consider the following actions:
• Provide all staff with common consistent definitions of pressure ulcer stages, such as guidelines from the
National Pressure Ulcer Advisory Panel.
• Adopt standard facility procedures for describing, measuring and evaluating pressure ulcers.
• Provide consistent tools – such as measurement guides and an assessment scale – throughout the home for
staff to use consistently
• Review and adapt your pressure ulcer plan of care
Question 13
This question identifies the misconception that a bed-ridden resident’s pressure ulcer requires surgery to heal.
Improved wound care products and pressure reduction devices have greatly increased the healing of pressure
ulcers without surgical interventions. If staff responded “True,” to this statement, consider:
• Demonstrating and discussing newer pressure-reduction products available to assist with wound healing and
discussing clinical indications
Question 14
If clinical staff answered “True” to this question they may need further education and information about why
pressure ulcers occur. Consider offering training on:
• Non-compliance with pressure ulcer plan of care
• Disease progression
• Poor nutritional intake
• Other pressure ulcer risk factors
For non-clinical staff additional information may include:
• Training on the etiology of pressure ulcer formation
• Reviewing the role of non-clinical staff in pressure ulcer prevention and treatment
• Reviewing risk factors
• Information on their specific role in the care process as it relates to pressure ulcers.
Question 15
If staff answered “True” to this statement, it indicates they understand the emotional impact a physical condition
can have on residents’ self-esteem. Pressure ulcers may limit the independence of the resident. They may also
contribute to a resident feeling ‘sick’ and dependent on others for care. Additionally, many pressure ulcers
occur in areas of the body that are emotionally uncomfortable for people to deal with, such as the buttocks.
Dignity may be compromised if the resident feels embarrassed or ashamed over having a pressure ulcer. Family
members may be angry at the facility or the resident. This could add to feelings of inadequacy the resident may
already be experiencing.
If anybody answered “False,” offer education to all staff, families and volunteers about pressure ulcers effect on
residents’ psychosocial well-being as well as their physical discomfort.
Question 16
Pressure ulcers may occur on any part of the body exposed to unrelieved pressure that decreased the flow of
blood a sufficient length of time to cause underlying tissue damage. A “False” answer to this question may
indicate that your staff does not understand the etiology of a pressure ulcer. Although pressure ulcers generally
are noted over boney prominences of the body, they can occur at any location where unrelieved pressure is
noted. Educational intervention may include:
• Pressure ulcer definition and staging guidelines
• Proper positioning and repositioning techniques
• Proper use of pressure reduction devices
• Frequent reinforcement that pressure ulcer prevention and treatment is everybody’s responsibility

MO-08-15-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not
necessarily reflect CMS policy.

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Gauging Pressure Ulcers:

II. Facility Assessment and Protocols

III. Resident Assessment and Monitoring Tools

continued on next page >

VI. Communication Among Providers

Regulations: Pressure Ulcers

Document available at www.primaris.org

CodingM1 - recording of all skin ulcers if caused by pressure or circulatory problems.

Document available at www.primaris.org

Directions for Pressure Ulcers: Facility Assessment Overview Questionnaire

Pressure Ulcers: Facility Assessment Yes No In Progress

When completing each checklist on the following pages:

Pressure Ulcers: Screening for Pressure Ulcer Risk

Completed by: _______________________________________ Date: ______________________________

Pressure Ulcers: Facility Assessment Checklists: page 3

Pressure Ulcers: Developing Care Plans

continued on next page >

Pressure Ulcers: Developing Care Plans

Completed by: _______________________________________ Date: ______________________________

Pressure Ulcers: Facility Assessment Checklists: page 5

Pressure Ulcers: Assessment and Reassessment

Completed by: _______________________________________ Date: ______________________________

Pressure Ulcers: Facility Assessment Checklists: page 6

Pressure Ulcers: Monitoring Treatment and Prevention

Completed by: _______________________________________ Date: ______________________________

Pressure Ulcers: Facility Assessment Checklists: page 7

Pressure Ulcers: Elimination

Completed by: _______________________________________ Date: ______________________________

Pressure Ulcers: Facility Assessment Checklists: page 8

Pressure Ulcers: Staff Training and Education

Completed by: _______________________________________ Date: ______________________________

Document available at www.primaris.org

At Risk Moderate High Risk Very High

undressing, toileting, bathing, peri­care, etc. Pay particular attention to bony prominences.

Turning and repositioning: Keep bony prominences from direct contact using systematic turning and

Written plan of care: Each resident’s care plan should be unique, including specific turning and

repositioning plans. Indentify and address each factor noted in the Risk Assessment.

Source: QIPMO: University of MO­Columbia, Sinclair School of Nursing, April 2008

Room #:_________ Attending Physician:_________________________Date of Assessment: _____________

Moderate Risk: Total score 13-14.

For Detailed Descriptions, see page 2

Sensory Perception Nutrition

Document available at www.primaris.org

Resident: ___________________________________________________________ Date:_________________

Skin Tear Risk Assessment Yes No Yes No

Skin Tear Prevention Protocol

Nurse Signature: _________________________________________ Date Protocol Initiated: __________________

Skin Tear Risk Assessment and Prevention Protocol—Audit

Related Federal Standard: “Quality of Care”

Criterion Instructions for

Document available at www.primaris.org

for dehydration. Initiate a plan of care if necessary based on your findings.

Medical Conditions/History: Medications:

Document available at www.primaris.org

Resident: _______________________________________________ Date:_____________________________

Indicate on the body chart any areas of concern:

Nurse Signature: _______________________________________________________ Date: ____________________

Document available at www.primaris.org

Weekly Skin Assessment Yes No

Licensed Nurse Signature: _________________________________________________ Date: __________________

Document available at www.primaris.org

Resident: _______________________________________________ Date:_______________________

CNA Signature:_________________________________________________________ Date: ____________________

Charge Nurse Signature: ________________________________________________ Date: ____________________

Completed by: _________ Date:

Completed by: _________ Date:

Completed by: _________ Date:

Completed by: _________ Date:

Completed by: _________ Date:

Completed by: _________ Date:

undressing, toileting, bathing, pericare, etc. Pay particular attention to bony prominences.

Source: QIPMO: University of MOColumbia, Sinclair School of Nursing, April 2008

Room #:_ Attending Physician:_____Date of Assessment: _

Resident: ___________________________________________ Date:_

Nurse Signature: _______________________ Date Protocol Initiated:

Resident: ___________________ Date:_

Nurse Signature: ___________________________________ Date:

Licensed Nurse Signature: _______________________________ Date:

Resident: _________________________ Date:_

CNA Signature:_____________________________________ Date:

Charge Nurse Signature: ____________________________ Date:

DON Signature: ____________________________________ Date:

Staff Name: ___________________________ Completion Date:_

Reviewer:__________________ Date of review: _

Treatment protocol approved by (signature) ______________________________ Date: