I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
Skin Assessment and Pressure Ulcer Care in Hospital-based Skilled Nursing Facilities
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P ressure ulcer prevalence varies by setting, but recent data suggest it may as high as 17% in acute care, 28% in long-term care, and 29% in home care settings.1 Regardless of the type of patient care environment, pressure ulcers are a significant healthcare problem because they increase the amount of nursing care required, the resident's length of stay, and healthcare costs.2 Prevention is the key to reducing pressure ulcer prevalence. The first step to pressure ulcer prevention is a thorough and complete initial nursing assessment of the patient upon admission. In order to prevent or reduce pressure ulcers, nursing staff must have an initial skin and pressure ulcer risk assessment on which to base their care.
In 1990, the Minimum Data Set (MDS) instrument was developed as a comprehensive assessment tool for residents in nursing homes receiving Medicare or Medicaid funding. The state of Missouri has been collecting data from the MDS on all residents in certified nursing home facilities since July 1992.3 In 1998, the federal government mandated that MDS data be submitted nationally to the Health Care Financing Administration (now the Center for Medicare and Medicaid Services, [CMS]). The MDS is currently used as a basis for clinical decision-making, as a research instrument, and as a basis for Medicare and Medicaid reimbursement. The MDS also provides information regarding the potential quality of nursing homes.4
Hawes and colleagues5 conducted an extensive study on the reliability of the MDS. Through their three field tests, revisions were made to the original MDS. After the revisions were completed, additional testing was done. Most recent testing showed that the MDS was reliable and that the explicit questions and use of multiple sources to score the MDS added to the validity and reliability of the tool.5 The average reliability of the stasis and pressure ulcer item (Section M, Items 2a and 2b) was 0.62.5
Within the MDS, pressure ulcer risk is "triggered" for further assessment by eight findings, including fecal incontinence, immobility, bedfast status, peripheral vascular disease, presence or history of a pressure ulcer, use of restraints, and desensitized skin.6 The MDS provides information regarding the number of pressure ulcers present, but it is beyond the scope of the instrument to identify how the assessment process and subsequent decisions about treatment are done. A modest amount of research has started to examine skin and wound care practices using the MDS in nursing homes.7-13 However, scant data are available regarding the prevalence and care of pressure ulcers in hospital-based skilled nursing facilities. Information regarding hospital-based skilled nursing facilities' methods to assess skin integrity and pressure ulcer risk and subsequent skin/pressure ulcer care is also lacking.
Hospital-based skilled nursing facilities are small, licensed nursing homes within a hospital or medical center. They are used in the continuum of care for hospitalized patients who need extended physician monitoring and are not sufficiently medically stable to go home or be transferred to a freestanding skilled nursing facility. By allowing such patients to stay within the hospital complex, the physician can continue to see the patient on a regular basis and have access to hospital auxiliary support services (x-rays, laboratory, and the like).
References:
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treatement and reimbursement of pressure ulcers continues to be costly, as hospitals spend millions on their budjets. Concequences like increased length of hospital stay have made them a priority nursing concern.
Reply to this comment »It has become almost imparative for nurses and physicians to perform a thorough comprehensive skin assessment of each admitted patient to ensure that not only are they identified, but at the same time, that a plan of care that addresses the treatement and alleviation of the different skin conditions is put in place.
My facility currently uses the braden score, an assessment tool that identifies high risk patients, to where the system fires a task in the daily RN assessment, to turn those who are identified as high risk.
Caroline Asava, RN, BSN
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