17 final... · web viewmedical devices (e.g. cpap, bidirectional positive airway pressure, oxygen...

of 35

Waterloo Wellington Integrated Wound Care ProgramEvidence-Based Wound Care

Pressure Injury Clinical Pathway0-7 Days Expected Outcomes Notes

Patient admitted to service/facility

Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed

Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patient Determine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and

consider additional supports availableMedical/surgical history and co-morbidity management considered within care plan

Any diagnosis that affects mobility, cognition, sensation and communication may be the cause of risk factors for Pressure Injurys

Sensory Perception Neuropathy Glycosylation (sugar attaches to cells)

of tissues Sensory impairment/altered level of

consciousness Decreased cognitive ability

Moisture Moisture on skin (e.g. bladder and bowel

incontinence, wound or fistula exudate, diaphoresis)

Edema Altered skin integrity/previous ulcerations

Activity (degree of physical activity) Immobility (bedrest, head of bed elevation

>300, chair sitting for prolonged times, hip fractures, supine or prone positioning)

Decreased level of activity Chronic or end of life pain Comorbidity that causes physical limitations

Mobility (ability to change and control body position) Obesity Prolonged anesthesia/operating room time Prematurity

Advanced age End of life Critically injured status Uncontrolled body movements Congenital abnormalities

Nutrition Nutritional deficits Alcohol/drug abuse

Friction, Pressure and Shear Unsafe transfers Medical devices (e.g. CPAP, bidirectional

positive airway pressure, oxygen tubing and masks, percutaneous endoscopic gastrostomy tubes, endotracheal tubes, nasogastric tubes, pelvic binders, pulse oximetry probes, tracheostomy faceplates and ties, sequential compression devices, external fixators and limb mobilizers)

Socioeconomic/Lifestyle Smoking Unsafe home environment Inadequate foot wear Inadequate hygiene Lack of awareness for self-care Financial insecurity Changes in routine

Current ongoing adjunctive therapies integrated into care plan

Waterloo Wellington Integrated Wound Care Program wwwoundcare.ca May 2016

of 35

Medication reconciliation and their impact on wound healing reviewed

Prescription, non-prescription, naturopathic and illicit drug use (including e-cigarettes, inhaled substances and nicotine replacement therapy)

Medications that can affect healing include:chemotherapy, anticoagulants, antiplatelets, corticosteroids, vasoconstrictors, antihypertensives, diuretics and immunosuppressive drugs

Other medications used to treat acute episodic illnesses may affect healing (eg. antibiotics, colchicine, anti-rheumatoid arthritics)

Vitamin and mineral supplementationRecent blood work and other diagnostic test results reviewed and implictions for wound healing considered

Determine bloodwork and other diagnostic tests required (see chart in guidelines) Ensure Albumin done during this time period

Home glycemic control and monitoring if diabetic BS and A1C are within recommended range per responsible physician or NP Ensure Albumin/Urine creatinine ratio done during this time period Use of glucose log book (Diabetes Passport) Adequate insulin supplies Glucometer and required supplies Assess for barriers in monitoring glycemic control Community/health resources

Link to Waterloo Wellington Diabetes Directory can be found at http://www.waterloowellingtondiabetes.ca/userContent/documents/Public-Resource%20Library/Waterloo%20Wellington%20Diabetes%20Directory%202015%20-%20proof%204.pdf

Diabetic Education ProgramPatient self-referral link http://www.waterloowellingtondiabetes.ca/Public-Referrals.htmMedical professional referral link http://www.waterloowellingtondiabetes.ca/Professional-Site-Referral-Page.htm

Physical examination performed Identify pressure points, contractures and areas of reddness (note if blanchable or non-blanchable) Evidence of previous pressure injury Use of Braden Risk Scale

Link: http://www.healthcare.uiowa.edu/igec/tools/pressureulcers/bradenscale.pdfIf Pressure injury is below knee: assess potential to heal

Bilateral lower leg assessment (LLA)completed

Complete: ABPI/TPBI completed within last 3 mths and results documented If unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies is recommended Repeat ABPI/TPBI assessment every 3 months if healing is not progressing Bilateral lower leg assessment that includes : Leg measurements (foot, ankle, calf, thigh) to assess edema Nail changes (thicker, dry, crumbly, presence of fungal infection) Assess interdigital spaces Presence of callous or corns Presence of varicosities (varicose veins) Ankle flare Drainage on socks History of compression

Wound and periwound assessment completed Complete: Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH)


ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies

ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult needed

A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing

Normal blood glucose ranges are needed for wound healing to occur

http://www.healthcare.uiowa.edu/igec/tools/pressureulcers/bradenscale.pdf

http://www.waterloowellingtondiabetes.ca/Professional-Site-Referral-Page.htm


http://www.waterloowellingtondiabetes.ca/Public-Referrals.htm

http://www.waterloowellingtondiabetes.ca/userContent/documents/Public-Resource%20Library/Waterloo%20Wellington%20Diabetes%20Directory%202015%20-%20proof%204.pdf%20

http://www.waterloowellingtondiabetes.ca/userContent/documents/Public-Resource%20Library/Waterloo%20Wellington%20Diabetes%20Directory%202015%20-%20proof%204.pdf%20

of 35

Measure and document size of wound Stage pressure injury Assess potential to heal Assess need for debridement Assessment for infection (NERDS and STONEES) Obtain photos following best practice as per framework for individual organization policies and

procedures. Suggest following publication as guideline: http://mydigitalpublication.com/publication/?i=206722

Link to Waterloo Wellington Integrated Guidelines for Pressure Injuries: http://wwwoundcare.ca/88/Provide_Local_Wound_Care/

National Pressure Ulcer Advisory Panel (NPUAP)


A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing

http://wwwoundcare.ca/88/Provide_Local_Wound_Care/

http://mydigitalpublication.com/publication/?i=206722

of 35

Staging System (Updated April 2016)

Stage 1Pressure Injury Intact skin with a localized area of non-blanchable erythema

May appear differently in darkly pigmented skin Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede

visual changes Colour changes do not include purple or maroon discolouration; these may indicate deep tissue

pressure injury

Stage 2Pressure Injury

Wound bed is viable, pink or red, moist May also present as an intact or ruptured serum-filled blister Adipose (fat) and deeper tissues are not visible• Granulation tissue, slough and eschar are not present• These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and

shear in the heel.• This stage should not be used to describe moisture associated skin damage (MASD) including

incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions)


Adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present Slough and/or eschar may be visible The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep

wounds. Undermining and tunneling may occur Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury


Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the injury


Non-blanchable erythema of intact skin

of 35

Slough and/or eschar may be visible Epibole (rolled edges), undermining and/or tunneling often occur Depth varies by anatomical location If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury

Unstageable Pressure Injury Extent of tissue damage within the injury cannot be confirmed as it is obscured by slough or eschar If slough or eschar is removed a Stage 3 or Stage 4 pressure injury will be revealed Stable eschar (i.e. dry, adherent, intact without erythema or fluctuant) on an ischemic limb or the heel(s) should

not be removed

Medical Device RelatedPressure Injury

This describes the etiology of the injury Result from the use of devices designed and applied for diagnostic or therapeutic purposes Resultant pressure injury generally conforms to the pattern or shape of the device Injury should be staged using the staging system

Mucosal MembranePressure Injury

Found on mucous membranes with a history of medical device in use at the location of the injury Due to the anatomy of the tissue these injuries cannot be staged

Moisture Associated Skin Damage (MASD) assessment completed

Assess continence of urine and stool If incontinence is a concern, a continence assessment should be completed by a qualified practioner (e.g.

an Enterstomal Therapist (ET) or Nurse Continence Advisor (NCA)


MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.

of 35

Skin assessment including skin folds Link to RNAO Prompted Voiding Best Practice Guidelines

http://rnao.ca/sites/rnao-ca/files/Promoting_Continence_Using_Prompted_Voiding.pdf

Pain management considered and initiated Complete: Brief Pain Inventory Short Form (BPI-SF) Identify type of pain

1. Neuropathic Pain (described as burning, stinging, shooting, stabbing or hyperesthesia – sensitivity to touch). Suggested pharmaceutical treatment: Second generation tricyclic agents – e.g. Nortriptyline or Desipramine. If pain is not relieved try using Gabapentin or Pregabalin.

2. Nociceptive pain (described as sharp, aching or throbbing). Suggested pharmaceutical treatment: Non-Opioids – e.g. ASA or Acetaminophen Mild Opioids – e.g. CodeineStrong Opioids – e.g. Morphine or Oxycodone

Obtain physician/nurse practitioner orders for pharmaceutical treatments (opioids and non-opioids) Non-pharmacological pain control options (support surfaces, repositioning) Coordinate analgesic administration with wound care treatment times

Patient’s nutritional status optimized Calculate Body Mass Index (BMI) Determine recent weight loss/gain Complete Mini Nutritional Assessment (MNA)

http://www.mna-elderly.org/forms/mini/mna_mini_english.pdf If screening section results < 11 = complete assessment section If assessment section results< 24 = Registered Dietician referral required Recent dietary consult Identify barriers or risk factors to healthy eating Link to EatRight Ontario to talk to dietician

www.eatrightontario.ca 1-877-510-5102Wound etiology and appropriate pathway established Identify initial cause of wound. Pressure injuries are localized injury to the skin and/or underlying

tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear

Patient and caregiver concerns and goals integrated into the care plan and shared with care team

Complete: Cardiff Wound Impact Questionnaire

ORWorld Health Organization Quality of Life (WHOQOL) form

Ensure all patient/caregiver goals and concerns been addressedWound treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable)

Arrange for physician/nurse practitioner orders as required to begin plan of care including agreeance to professional referral recommendations

Identify cause of pressure Provide pressure redistribution (support surfaces) for sleep, seating and use of medical devices Debridement/reduction by qualified professional Re-visit to pressure redistribution professional is recommended Ensure appropriate skin care Identify any potential barriers to wound treatment plan


Pain Red FlagsPossible Infection

Increase in pain level (new pain in patients with altered sensation )

Possible Arterial Involvement Pain on walking (caused by intermittent claudication) Pain with elevation of lower limbs Rest pain Nocturnal pain

Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or above

Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations.

When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.

Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined

http://www.eatrightontario.ca/

http://www.mna-elderly.org/forms/mini/mna_mini_english.pdf


of 35

Identify appropriate footwear, offloading and repositioning options Consider required referals and further follow-up with previous professional referrals Consider compression if venous insufficiency/edema present and if APBI/TPBI is within safe range

Link to Waterloo Wellington Venous Leg Guidelines – Compression: http://wwwoundcare.ca/102/ Utilize toolkit to determine wound cleansing, debridement and dressing selection (South West

Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart)

Pressure Redistribution Ensure appropriate referrals for pressure redistribution have been arranged to qualified professionals

Review correct use of appropriate pressure redistribution devices Assess need for support surface (chair/bed)

Link to chart in guidelines: http://wwwoundcare.ca/81/Pressure_Reduction_and_Relief/ Review adherence to using appropriate pressure redistribution device(s) Assess barriers to appropriate pressure redistribution Initial and ongoing callous reduction is part of pressure redistribution Assess for secondary complications of offloading and refer concerns to treating practitioner

Look for redmarks, blisters, skin abrasions Ask about knee, hip or back issues (including contralateral limb) due to height difference of

offloading device Check for unsafe gait (are they stable, using appropriate aids, etc) Teach patient to assess for secondary complications

Check gait aids such as walker, cane, crutches Review goals of pressure redistribution (i.e. transition from cast to shoes, foot orthoses, etc.) Check for availability for financial compensation (e.g. private insurance, veterans medical benefits,

Assistive Devices Program (ADP), Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)

Patient counselled on the benefit of activity and rest for wound healing and comfort measures

Recent changes in overall activity level Daily routine including continence

concerns and/or access to bathroom Personal assistance available to perform

activities of daily living Determine where patient sleeps at night

and sits during day Safety of transfers Pressure distribution device

Consider Occupational Therapist referral for pressure redistribution device

Assess barriers to sleeping in bed Assess mobility and dexterity aids currently

being used (bedrail, superpole, trapezebar, therapeutic surfaces, raised toilet set and sitting devices)

Recommendations for exercise

Patient/caregiver educational plan initiated Rest/Activity Turning and sitting schedule for

repositioning Pillow between knees

Safety

Dietary Dietary requirements as per dietician Blood

glucose testing and recording in diary Link to EatRight Ontario to talk to dietician

www.eatrightontario.ca 1-877-510-5102


Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined

‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.


http://wwwoundcare.ca/81/Pressure_Reduction_and_Relief/

http://wwwoundcare.ca/102/

of 35

Prevention of injury – friction, shearing When to call primary caregiver (eg. signs

and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)

Pressure Relief/redistribution surface Offloading is required ‘for life’ Understands need of debridement Encourage appropriate footwear to be

worn at all times when weight bearing as discussed with foot care specialist

Examination of footwear, orthotics and offloading devices for foreign objects, wear pattern, pressure points and presence of wound drainage

Lifestyle Smoking and e-cigarette cessation with

goal to be nicotene-freeGuidelines can be found at:http://rnao.ca/sites/rnao-ca/files/Integrating_Smoking_Cessation_into_Daily_Nursing_Practice.pdf

Pain managementWound

Self care of wound

Diagnostic Tests Results understood by patient Diagnostic testing (nutritional blood work and

cholesterol levels) If diabetic, target ranges for A1C and blood

sugar Skin Care Wound self care Holistic self care of skin Incontinence and prevention/treatment of

Moisture Associated Skin Damage (MASD)Community Supports

Seating clinic for wheelchair Community support groups (eg. Diabetic

education and self- management sessions, walking groups, Southern Ontario Aboriginal Diabetes Initiative - SOADI)


Other ____________________________

Ability to self-manage optimized Review for independence or need for ongoing assistance with the following: Barriers to participate (poor eyesight,

physical limitations, transportation, socioeconomic, social environment, cognitive ability, other co-morbidities)

Decreased sensory perception affects ability to respond to pressure-related issues

Review importance and potential barriers to smoking cessation at every visit

Pressure relief/redistribution Adequate hygiene skin exposed to

moisture, perspiration Daily foot inspection with mirror(including

bottom of foot and between toes) Ongoing footcare arranged Home Environment – ADL’s

Compression application and removal if prescribed


Social/medical/family/employment obligationsSuggested website for reviewhttp://www.wwselfmanagement.ca/

Other ____________________________


http://www.wwselfmanagement.ca/

http://www.waterloowellingtondiabetes.ca/userContent/documents/Public-Resource%20Library/Waterloo%20Wellington%20Diabetes%20Directory%202015%20-%20proof%204.pdf






http://rnao.ca/sites/rnao-ca/files/Integrating_Smoking_Cessation_into_Daily_Nursing_Practice.pdf



of 35

Wound care Nutrition

Coping strategies implemented into plan of care Promoting independence to avoid practitioner/caregiver dependency Patient’s concerns and fears (including practitioner dependence) Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form –GDS15 Suicide assessment if applicable ETOH and illicit/recreational drug use Check for availability for financial compensation (e.g. private insurance, ADP, veterans medical

benefits, Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)

Family and caregiver support identified and incorporated into plan of care

Family/caregiver actively able to participate in treatment plan Repositioning, nutrition, continence if needed Importance of caregiver respite/relief

Social supports/community resources currently utilized is integrated into plan of care

Family support Check for availability for financial compensation (e.g. private insurance, veterans medical benefits,

Ontario Disability Support Program –ODSP/Ontario Works, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)

Community/health resourcesLink to Waterloo Wellington Diabetes Directory can be found at http://www.waterloowellingtondiabetes.ca/userContent/documents/Public-Resource%20Library/Waterloo%20Wellington%20Diabetes%20Directory%202015%20-%20proof%204.pdf

Caregiver conflicts Long or short term placement Confirm that ongoing medication coverage is arranged

Link to Trillium Drug Benefitshttp://www.health.gov.on.ca/en/public/programs/drugs/programs/odb/opdp_trillium.aspx

Professional referrals are initiated Primary Care Physician Community Nursing Advanced Wound Specialist Nurse Practitioner Occupational Therapist Urologist Infectious Disease Specialist Vascular Surgeon Orthopedic Surgeon Dermatologist Plastic Surgeon Internist/Endocrinologist Nephrologist Cardiologist Opthalmologist/Optometrist Mental Health Specialist

Physiotherapist Physiatrist Registered Kinesiologist Chiropodist Diabetic Education Program

Patient self-referral link http://www.waterloowellingtondiabetes.ca/Public-Referrals.htmMedical professional referral link http://www.waterloowellingtondiabetes.ca/Professional-Site-Referral-Page.htm

Certified Pedorothist Certified Orthotist Certified Prosthetist Podiatrist Footcare Nurse






http://www.health.gov.on.ca/en/public/programs/drugs/programs/odb/opdp_trillium.aspx



of 35

Psychologist/Psychiatrist Social worker Registered Dietitian Pharmacist Neurologist

Lymphatic Massage Therapist Compression Stocking Fitter Other___________________________

Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendationsAppropriate documents shared

Pressure mapping Diagnostic results Identify need to reassess ABPI/TPBI in 6 months Lower leg assessment results Recent vascular study results (eg. ABPI, TPBI,

Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)

Relevant consultation notes Post and current treatment and education plan List of appropriate contact information for ongoing

needs

If wound closed or eschar is stable (in arterial disease) send discharge summary outlining outstanding issues and teaching completed to:

Referral source Most responsible physician (MRP)/nurse

practitioner

Acute care Complex Continuing Care/Rehab Long-term care Community care Primary care physician/Nurse Practioner Professionals referred to Other _____________________________

8-21 Days Expected Outcomes NotesMost Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed

Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient’s condition.


consider additional supports available

If Pressure injury is below knee: assess potential to heal Complete:


‘Closed’ vs ‘Healed’

Closed : Skin intact, underlying tissue or structures are not visible Healed : Wound has been closed for a 2 year time period allowing

for collagen re-modelling from type 3 to type 1

These terms are often mistakenly used interchangeably.

Understand and teach the difference!

of 35

Bilateral lower leg assessment (LLA)completed ABPI/TPBI completed within last 3 mths and results documented If unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies is recommended Repeat ABPI/TPBI assessment every 3 months if healing is not progressing Bilateral lower leg assessment that includes : Leg measurements (foot, ankle, calf, thigh) to assess edema Nail changes (thicker, dry, crumbly, presence of fungal infection) Assess interdigital spaces Presence of callous or corns Presence of varicosities (varicose veins) Ankle flare Drainage on socks History of compression

Wound and periwound assessment completed Complete: Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH) Measure and document size of wound Stage pressure injury Assess potential to heal Assess need for debridement Assessment for infection (NERDS and STONEES) Obtain photos following best practice as per framework for individual organization policies and



Wound treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable)

Arrange for physician/nurse practitioner orders as required including agreeance to professional referral recommendations

Identify cause of pressure Provide pressure redistribution (support surfaces) for sleep, seating and use of medical devices Debridement/reduction by qualified professional Re-visit to pressure redistribution professional is recommended Ensure appropriate skin care Identify any potential barriers to wound treatment plan Identify appropriate footwear, offloading and repositioning options Consider required referals and further follow-up with previous professional referrals Consider compression if venous insufficiency/edema present and if APBI/TPBI is within safe range






Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP order

A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan may include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also recommended.





of 35

an Enterstomal Therapist (ET) or Nurse Continence Advisor (NCA) Skin assessment including skin folds Link to RNAO Prompted Voiding Best Practice Guidelines













Medical/surgical history and co-morbidity management considered within care plan

Review for changes


Review for changes: Prescription, non-prescription, naturopathic and illicit drug use









of 35

Recent blood work and other diagnostic test results reviewed and implictions for wound healing considered

Determine bloodwork and other diagnostic tests required (see chart in guidelines)

Home glycemic control and monitoring if diabetic BS and A1C are within recommended range per responsible physician or NP Use of glucose log book (Diabetes Passport) Adequate insulin supplies Glucometer and required supplies Assess for barriers in monitoring glycemic control Community/health resources


Diabetic Education ProgramPatient self-referral link http://www.waterloowellingtondiabetes.ca/Public-Referrals.htmMedical professional referral link http://www.waterloowellingtondiabetes.ca/Professional-Site-Referral-Page.htm



www.eatrightontario.ca 1-877-510-5102Patient and caregiver concerns and goals integrated into the care plan and shared with care team

Review for changes: Cardiff Wound Impact Questionnaire


Ensure all patient/caregiver goals and concerns been addressedPatient counselled on the benefit of activity and rest for wound healing and comfort measures




and sits during day Safety of transfers Pressure distribution device

Consider Occupational Therapist referral for pressure redistribution device

Assess barriers to sleeping in bed Assess mobility and dexterity aids currently

being used (bedrail, superpole, trapezebar, therapeutic surfaces, raised toilet set and sitting devices)

Recommendations for exercise

Patient/caregiver educational plan Rest/Activity Turning and sitting schedule for

repositioning


glucose testing and recording in diary




‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm







of 35

Pillow between kneesSafety









Self care of wound

Link to EatRight Ontario to talk to dieticianwww.eatrightontario.ca 1-877-510-5102

Diagnostic Tests Results understood by patient Diagnostic testing (nutritional blood work and







Other ____________________________







bottom of foot and between toes)




Other ____________________________


‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm












of 35

Ongoing footcare arranged Home Environment – ADL’s Wound care Nutrition

Coping strategies implemented into plan of care Promoting independence to avoid practitioner/caregiver dependency Patient’s concerns and fears (including practitioner dependence) Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form –GDS15 Suicide assessment if applicable ETOH and illicit/recreational drug use

Check for availability for financial compensation (e.g. private insurance, ADP, veterans medical benefits, Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)









Professional referrals are initiated Primary Care Physician Community Nursing Advanced Wound Specialist Nurse Practitioner Occupational Therapist Urologist Infectious Disease Specialist Vascular Surgeon Orthopedic Surgeon Dermatologist Plastic Surgeon Internist/Endocrinologist Nephrologist Cardiologist



Certified Pedorothist Certified Orthotist Certified Prosthetist









of 35

Opthalmologist/Optometrist Mental Health Specialist Psychologist/Psychiatrist Social worker Registered Dietitian Pharmacist Neurologist

Podiatrist Footcare Nurse Lymphatic Massage Therapist Compression Stocking Fitter Other___________________________





needs



practitioner



‘Closed’ vs ‘Healed’

Closed : Skin intact, underlying tissue or structures are not visible Healed : Wound has been closed for a 2 year time period allowing

for collagen re-modelling from type 3 to type 1

These terms are often mistakenly used interchangeably.

Understand and teach the difference!

of 35

21-28 Days Expected Outcomes (Ongoing to day 76) NotesMost Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed



consider additional supports available

If Pressure injury is below knee: assess potential to heal


Complete:1. ABPI/TPBI completed within last 3 mths and results documented2. If unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies is recommended3. Repeat ABPI/TPBI assessment every 3 months if healing is not progressing4. Bilateral lower leg assessment that includes : Leg measurements (foot, ankle, calf, thigh) to assess edema Nail changes (thicker, dry, crumbly, presence of fungal infection) Assess interdigital spaces Presence of callous or corns



of 35

Presence of varicosities (varicose veins) Ankle flare Drainage on socks History of compression

Wound and periwound assessment completed Complete: Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH) Measure and document size of wound Stage pressure injury Assess potential to heal Assess need for debridement Assessment for infection (NERDS and STONEES) Obtain photos following best practice as per framework for individual organization policies and
















Possible Arterial Involvement Pain on walking (caused by intermittent claudication)




A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan should include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also recommended.




of 35












Review for changes





Home Glycemic Control and Monitoring if diabetic BS and A1C are within recommended range per responsible physician or NP Use of glucose log book (Diabetes Passport) Adequate insulin supplies Glucometer and required supplies




Possible Arterial Involvement Pain on walking (caused by intermittent claudication)



of 35

Assess for barriers in monitoring glycemic controlPatient’s nutritional status optimized Calculate Body Mass Index (BMI)

Determine recent weight loss/gain Complete Mini Nutritional Assessment (MNA)





Ensure all patient/caregiver goals and concerns been addressedPatient counselled on the benefit of activity and rest for comfort measures and wound healing




and sits during day Safety of transfers

Pressure relief device &/or redistribution Assess barriers to sleeping in bed Assess mobility and dexterity aids currently

being used (bedrail, superpole, trapezebar, airbed)

Recommendations for exercise Consider Occupational Therapist referral for

pressure relief devicePatient/caregiver educational plan continued Rest/Activity

Turning and sitting schedule for repositioning






Examination of footwear, orthotics and offloading devices for foreign objects, wear pattern, pressure points and



www.eatrightontario.ca 1-877-510-5102Diagnostic Tests

Results understood by patient Diagnostic testing (nutritional blood work and





education and self- management sessions,







of 35

presence of wound drainageLifestyle

Smoking and e-cigarette cessation with goal to be nicotene-freeGuidelines can be found at:http://rnao.ca/sites/rnao-ca/files/Integrating_Smoking_Cessation_into_Daily_Nursing_Practice.pdf


Self care of wound

walking groups, Southern Ontario Aboriginal Diabetes Initiative - SOADI)


Other ____________________________







bottom of foot and between toes) Ongoing footcare arranged Home Environment – ADL’s Wound care Nutrition




Other ____________________________
















of 35







Professional referrals are initiated Primary Care Physician Community Nursing Advanced Wound Specialist Nurse Practitioner Occupational Therapist Urologist Infectious Disease Specialist Vascular Surgeon Orthopedic Surgeon Dermatologist Plastic Surgeon Internist/Endocrinologist Nephrologist Cardiologist Opthalmologist/Optometrist Mental Health Specialist Psychologist/Psychiatrist Social worker Registered Dietitian Pharmacist Neurologist



Certified Pedorothist Certified Orthotist Certified Prosthetist Podiatrist Footcare Nurse Lymphatic Massage Therapist Compression Stocking Fitter Other___________________________

Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations

Appropriate documents shared Pressure mapping Diagnostic results Identify need to reassess ABPI/TPBI in 6 months Lower leg assessment results

Acute care Complex Continuing Care/Rehab Long-term care Community care









of 35

Recent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)


needs



practitioner

Primary care physician/Nurse Practioner Professionals referred to Other _____________________________

77-84 Days Expected Outcomes (Ongoing to day 90) NotesMost Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed



consider additional supports availableIf Pressure injury is below knee: assess potential to heal


Complete: ABPI/TPBI completed within last 3 mths and results documented If unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies is recommended Repeat ABPI/TPBI assessment every 3 months if healing is not progressing Bilateral lower leg assessment that includes : Leg measurements (foot, ankle, calf, thigh) to assess edema Nail changes (thicker, dry, crumbly, presence of fungal infection) Assess interdigital spaces Presence of callous or corns Presence of varicosities (varicose veins) Ankle flare Drainage on socks History of compression

Wound and periwound assessment completed Complete:




of 35

Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH) Measure and document size of wound Stage pressure injury Assess potential to heal Review etiology and consider biopsy if not healing Assess need for debridement Assessment for infection (NERDS and STONEES) Obtain photos following best practice as per framework for individual organization policies and























A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan should include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also recommended.



of 35







Check gait aids such as walker, cane, crutches Review goals of pressure redistribution (i.e. transition from cast to shoes, foot orthoses, etc.)

Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Assistive Devices Program (ADP), Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)


Review for changes





Home Glycemic Control and Monitoring if diabetic BS and A1C are within recommended range per responsible physician or NP Use of glucose log book (Diabetes Passport) Adequate insulin supplies Glucometer and required supplies Assess for barriers in monitoring glycemic control


http://www.mna-elderly.org/forms/mini/mna_mini_english.pdf If screening section results < 11 = complete assessment section






of 35

If assessment section results< 24 = Registered Dietician referral required Recent dietary consult Identify barriers or risk factors to healthy eating Link to EatRight Ontario to talk to dietician





















goal to be nicotene-freeGuidelines can be found at:http://rnao.ca/sites/rnao-ca/files/










Link to Waterloo Wellington Diabetes Directory can be found at http://www.waterloowellingtondiabetes.ca/userContent/documents/Public-Resource








of 35

Integrating_Smoking_Cessation_into_Daily_Nursing_Practice.pdf


Self care of wound

%20Library/Waterloo%20Wellington%20Diabetes%20Directory%202015%20-%20proof%204.pdf

Other ____________________________











Other ____________________________

Coping strategies implemented into plan of care Promoting independence to avoid practitioner/caregiver dependency Patient’s concerns and fears (including practitioner dependence) Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form –GDS15 Suicide assessment if applicable ETOH and illicit/recreational drug use

Check for availability for financial compensation (e.g. private insurance, ADP, veterans medical benefits, Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)






Community/health resourcesLink to Waterloo Wellington Diabetes Directory can be found at










of 35











Relevant consultation notes Post and current treatment and education plan










of 35

List of appropriate contact information for ongoing needs



practitioner

91-98 Days Expected Outcomes NotesMost Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed



consider additional supports availableIf Pressure injury is below knee: assess potential to heal


Complete: ABPI/TPBI completed within last 3 mths and results documented If unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies (arterial segmented

pressures) is recommended Repeat ABPI/TPBI assessment every 3 months if healing is not progressing Bilateral lower leg assessment that includes : Leg measurements (foot, ankle, calf, thigh) to assess edema Nail changes (thicker, dry, crumbly, presence of fungal infection) Assess interdigital spaces Presence of callous or corns Presence of varicosities (varicose veins) Ankle flare Drainage on socks History of compression

Wound and periwound assessment completed Complete: Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH) Measure and document size of wound Stage pressure injury Assess potential to heal Assess potential to heal Review etiology and consider biopsy if not healing Assess need for debridement


A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan may include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also recommended.



of 35

Assessment for infection (NERDS and STONEES) Obtain photos following best practice as per framework for individual organization policies and



























of 35








Review for changes





Home Glycemic Control and Monitoring if diabetic BS and A1C are within recommended range per responsible physician or NP Use of glucose log book (Diabetes Passport) Adequate insulin supplies Glucometer and required supplies Assess for barriers in monitoring glycemic control



www.eatrightontario.ca 1-877-510-5102







of 35

Patient and caregiver concerns and goals integrated into the care plan and shared with care team






















Self care of wound











Other ____________________________










of 35











Other ____________________________

















of 35






Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendations

Appropriate documents shared Pressure mapping Diagnostic results Identify need to reassess ABPI/TPBI in 6 months Lower leg assessment results Recent vascular study results (eg. ABPI, TPBI,



needs

If wound closed or eschar is stable (in arterial disease) send discharge summary outlining outstanding issues and








of 35

teaching completed to: Referral source Most responsible physician (MRP)/nurse

practitioner


17 final... · web viewmedical devices (e.g. cpap, bidirectional positive airway pressure, oxygen...

Documents