Communicating: Old Topic, Ongoing Issues

1. Communicating: Old Topic, Ongoing Issues Joyce Black, PhD, RN

2. Ideal communcation • Expresses ideas and facts clearly • Legible • Spelled correctly • Provides a record for later reference • Provides evidence of care provided

3. Ideal pressure ulcer communication • Date of occurrence • Events and diseases preceding ulcer development • Often assume wound is from one etiology when the true story is not known, or not carried forward • Past care rendered and outcomes (trajectory) • Current size, stage, other variables • Expected outcomes from patient’s perspective

4. What is often communicated? • Decubitus ulcer on buttocks

5. What if you knew this….. • 67 year old female who developed a sacral pressure ulcer following surgery 7 days ago • Ulcer found 2 days after surgery, it was a deep tissue injury • Placed her on low air loss bed for past 5 days and limited supine position • Has a Foley in place, oral nutrition is OK • Currently ulcer is 5 x 6 x ?, it is unstageable: fully eschar covered • Just started debridement today, had been treating it with foam dressings and skin barrier before

6. Improving interagency /interfacility communication • Standard data set components inconsistent from site to site • Standard transfer form inadequate • In the interim, ask • Stage, size, other attributes • Date of onset, events leading to ulcer • Initial care and outcome • Current care and plan for future • Patient and family aware

7. Inter-Professional Communication • Current problems • Ulcers “not discovered” until stage II or beyond • Staging errors • Wounds that are not pressure ulcers are staged • Frequency of assessment not consistent • Analysis of findings not apparent • Deterioration of ulcer not addressed

8. Addressing the issues • Ulcers not discovered until stage II or beyond • Plan of correction • Teach aides to report any skin issues that are not normal • Over-reporting should be appreciated • Teach aides to examine high risk areas • Heels by looking at the heel • Sacrum by separating buttocks folds • Expect full skin assessment by licensed nurses • Provide a documentation system to capture the assessment and the findings • “No new skin problems” always invites concern when ulcers are known to be present

9. Addressing staging issues Teach staging with photos Validate it in real patients Monitor accuracy Once full thickness, the ulcer is “a healing stage III/IV”

10. Correctly labeling other wounds • Stage II pressure ulcers are fairly rare • Skin lesions incorrectly classified as stage II’s often include • Incontinence associated dermatitis • Skin tears • Intertriginous dermatitis • Dehisced incisions • Important to clarify in training • Pressure ulcers in areas subject to pressure • Wet and dry skin more prone to ulcerate • Pressure ulcers should heal if etiology corrected an healing supported • Other skin lesions heal on different trajectory • Pressure ulcers are a quality issue, other conditions are not always monitored in same manner

11. Correcting the time factor • Weekly assessment of skin in low and moderate risk residents OK in most cases • As long as risk assessment is accurate • Daily assessment of skin in high risk residents needed • Examine skin as resident is turned or cleaned • Do not position back on the red area • Assessment of ulcer • With each dressing change • If healing, note wound is unchanged or stable • If no change for 2 weeks, reevaluate

12. Recording the analysis • Ulcers should heal • That is, size decreases, necrotic tissue is less, slough decreases or is absent, granulation tissue appears and is pink • When ulcer is not healing, • Do not continue present treatments (they aren’t working) • Document review of offloading (turning, surface), nutrition (diet and intake, weight change), topical treatments (dressing type, change frequency, etc) • Document plan to change, notification of family, preference of resident for treatment, contact with MD or WOCN

13. Communication is critical for proper care