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Protecting Veterans from Pressure Ulcers/Injuries

Healthcare provider putting on surgical gloves.
Use gloves to reduce the risk of infection.

Pressure ulcers/injuries are a growing problem in the healthcare setting. This is because treating pressure ulcers/injuries requires time and resources. This adds to your workload and puts an increased financial burden on facilities. Most important, pressure ulcers/injuries cause pain and slow patient recovery. For these reasons, it’s important to help prevent pressure ulcers/injuries with attentive care and speed healing with proper treatment.

A complex problem

Pressure ulcers/injuries are localized injuries to the skin or underlying tissue due to unrelieved pressure. This puts patients with immobility issues at greatest risk of developing pressure ulcers/injuries. Other health problems can also dramatically increase their risk. Yet even under such challenging conditions, most pressure ulcers/injuries can be prevented if proper steps are taken.

Steps for care

  • Check each patient's pressure ulcer/injury risk upon admission and throughout the patient's stay.

  • Document your findings in detail.

  • Prevent ulcers/injuries by limiting time patients spend in one position.

  • Involve family members in prevention efforts from the start.

  • Evaluate an existing pressure ulcer/injury to determine its stage.

  • Treat pressure ulcers/injuries quickly and properly to speed healing.

  • Reduce risk of infection by using gloves and practicing the proper handwashing technique.

  • Providers along with the interprofessional care team will develop and implement the care plan.

    • Note: Document your verbal alert/communication to the provider.

Check patient risk upon admission

Every patient requires an initial risk assessment upon admission. This involves performing a thorough skin assessment and gathering the patient's information. The patient's risk factors for pressure ulcers/injuries should also be listed in the assessment. Use the risk assessment tool, such as the Braden Scale or Norton Scale, approved by your facility. Be sure to document whether your patient is any of the following:

  • Immobile or inactive

  • Underweight or overweight

  • Malnourished or dehydrated

  • Incontinent

  • Ill with systemic disease, such as diabetes or anemia

  • Recovering from surgery

  • Medicated with steroids or sedatives

  • Edematous

  • Sensory impaired or has an altered level of consciousness

Check and document patient progress

Thorough assessment and proper documentation are vital for monitoring patient progress. Both should be performed during each shift. Assessment and documentation also show that you and others at your facility are taking all the appropriate steps to prevent, manage, and treat pressure ulcers/injuries.

  • Check with care. Properly check each patient for pressure ulcer/injury stage. Be particularly mindful when examining for pressure ulcers/injuries in patients with dark skin tones. It can be difficult to determine changes in skin color.

  • Document with care. Once you've checked the patient and staged the ulcer/injury, document your findings. Remember to be thorough and descriptive. Doing so gives a clear account of the wound's state and progress. Document the following:

    • The patient's level of pain using your facility's pain scale.

    • The length, width, and depth of the pressure ulcer/injury.

    • The type of wound tissue present, such as slough or granulation.

    • If any exudate is present and its characteristics, such as if it is serosanguinous fluid. Also note the amount, color, consistency, and odor of drainage.

    • The presence of a tunnel or sinus tract. Also note undermining.

    • The condition of surrounding skin. Note any signs of infection, such as redness or warmth of skin, or injuries due to pressure, tape, or other causes.

Caution. Never reverse stage or "backstage" a healing pressure ulcer/injury. For example, do not list a healing Stage 4 as a Stage 3. Instead, continue documenting the ulcer's/injury's characteristics relative to its initial stage. 

Professional resources

A variety of professional resources are available to help you care for and prepare your patients for discharge. Your facility may even have a skin care team that makes "skin care rounds." Be sure to take advantage of all the resources available for preventing and treating pressure ulcers/injuries. Follow your facility's protocol for referring patients to other specialists. Some of these specialists include:

  • Occupational therapist or physical therapist

  • Dietitian

  • Wound-care specialist

  • Nurse practitioner, physician assistant, physician or surgeon

  • Infectious disease specialist

  • Diabetes educator

To learn more

For more information, go to the Pressure Ulcer/Injury Resource mobile app.

Author: StayWell Custom Communications
Last Annual Review Date: 8/1/2018
Copyright © The StayWell Company, LLC. except where otherwise noted.
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