Willow Creek Healthcare Center

professional standards of practice.During a review of the facility policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol dated April 2018, the policy and procedure indicated, .The nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length and depth, presence of exudates (fluid that leaks from blood vessels into surrounding tissues or cavities, rich in protein, cells, and solid materials) and necrotic tissue (dead or dying tissue).the staff.will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions.the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or poor-healing wounds.the physician will help identify factors contributing or predisposing resident to skin breakdown.the physician will order pertinent wound treatments, including pressure reducing surfaces, wounds cleaning and debridement (the removal of damaged tissue) approaches, dressings and application of topical agents (a medication or substance applied to a specific area of the body's surface, such as the skin) .when wounds are not healing as anticipated or new wounds develop. current approaches should be reviewed for whether they remain pertinent to the resident medical conditions, are affected by factors influencing wound development or healing and the impact of specific treatment choices.During a review of a professional reference titled, Pressure Ulcer, dated January 2024, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK553107/ the professional reference indicated .

Examine the following in a patient with a PI (a localized area of skin and/or underlying tissue damage that develops when prolonged pressure or shear forces exceed the tissue's tolerance): Ulcer history, including etiology (the study of the cause or origin of a disease or abnormal condition) , duration, and previous treatment, Staging by thoroughly examining the depth of the wound, which this activity will cover in detail under staging, Size of the affected area, Sinus tracts (an abnormal, tube-like passage that connects an infected area to the surface of the skin), undermining (the lifting and separation of skin and underlying tissues), and tunneling (creating or traversing a passage), The presence of drainage, The presence of necrotic tissue.

When evaluating the wound characteristics, it is also important to keep risk assessment instruments in mind to reduce the risk of a PI incidence.

The primary goal is to prevent pressure injury.

This goal requires an interprofessional team, including primary care providers, wound care specialists, surgeons, specialty-trained wound nurses, physical therapists, and nurse aides.

Nurses provide care, monitor patients, and notify the team of issues.

Nurse aides are often responsible for turning and repositioning patients.The patient should be kept pain-free by giving analgesics (medications that relieve pain) .

They should try to increase physical activity, which a nurse's aide, medical assistant, or rehab nurse can facilitate.

Frequent follow-ups are an absolute necessity, and a team approach to patient education and pressure injury management involving the wound care nurse and wound care clinician lead to the best results.

Facility ID: