An initial skin evaluation should be performed immediately upon admission of a resident to the LTC facility. An ulcer can develop after only a few hours of pressure. Any discovered wounds should prompt thorough patient assessment and a subsequent treatment plan that includes a timeline for wound reassessment. This assessment involves a complete medical evaluation of the patient including careful attention to conditions that may affect both wound development and healing. A comprehensive wound history should note the onset and duration of a wound, and any previous wound care. Assessment of a person’s cognitive status, behavior, financial resources, and access to caregivers can impact a treatment plan.

Assessment of the patient’s personal environment is also critical. Frequency of repositioning, surfaces, turning schedules, transferring techniques, and durable medical equipment (such as assistive devices, trapeze, bed rails, and padding) can all impact wound development and healing [9]. Risk assessment scales may increase awareness, but have limited predictability and effectiveness in pressure ulcer prevention [22]. A meta-analysis of 33 studies demonstrated a lack of evidence for risk assessment scales in decreasing pressure ulcer incidence, but the scales did increase preventive interventions [23]. The two most commonly used tools are the Braden and Norton scales. No conclusive evidence exists showing that one is superior to the other.

Most nursing facilities use a pressure ulcer report to document identified wounds: location, stage, measurement, and description. Pressure ulcer reports fulfill standardized documentation as mandated by both state and federal (F314) regulations in the nursing facility. The clinician should document the number, location, and size (length, width, and depth in centimeters) of wounds and assess for the presence of exudates, odor, sinus tracts, necrosis or eschar formation, tunneling/undermining, infection, healing (granulation and epithelialization), and wound margins. For a pressure ulcer, the clinician should determine the stage of the ulcer according to the National Pressure Ulcer Advisory Panel (NPUAP) Staging System (see Table 2).

Risk of developing pressure ulcers is significantly high within the first 4 weeks after admission to a long-term care facility [25]. After an initial assessment, a weekly reassessment should occur for the first 4 weeks, followed by at least a quarterly assessment. Reassessments should also occur when there is a change in patient status [26]. The patient’s overall clinical condition should be reassessed whenever a pressure ulcer fails to show evidence of healing within 2–4 weeks of any intervention [25]. Every nursing facility is required to develop and implement its own comprehensive wound care plan in accordance with CMS regulations.

Some patients develop pressure ulcers 2–3 days before death. These are referred to as Kennedy terminal ulcers and are markers of the dying process. The Kennedy ulcer often develops suddenly on the sacrum as a blister or stage 2 and rapidly progress to stage 3 or 4. These ulcers can be pear-, horseshoe-, or butterfly-shaped with irregular borders. Kennedy terminal ulcers are initially red/purple, then turn to yellow, and finally turn black. The etiology is unclear, but is thought to be part of multiorgan failure. Most of the ulcers do not heal and their treatment is the same as that for pressure ulcers [27].

A wound may not necessarily fit into one of the four general categories of wounds (pressure ulcer, diabetic, arterial and venous), but may be of mixed etiology. Usually the type of wound can be distinguished by its location, combined with inspection of the wound and the patient’s clinical history. If the wound type remains uncertain, laboratory and/or radiographic studies may help clarify its type. For example, in lower extremity ulcers, an ankle-brachial index or Doppler arterial studies can help determine whether the ulcer is caused by vascular insufficiency, pressure or a combination of the two.

Paramount to wound care management is prevention. The Agency for Health Care Policy and Research (AHCPR ) published two companion practice guidelines in 1994 with recommendations for prediction, prevention and early treatment of pressure ulcers in adults [31, 32]. The companion practice guidelines were pioneering in their scope and are still widely utilized today because they remain applicable in many settings. The first step recommended for the prevention of pressure ulcers by the Institute for Healthcare Improvement (IHI) is to identify patients at risk, and then implement prevention strategies in these patients [24]. The IHI suggests “six essential elements of pressure ulcer prevention” in its guidelines.

The six steps are [24, 33]:

The IHI recommends that prevention measures include a comprehensive treatment plan with risk factor reduction, multidisciplinary interventions, functional adaptation, environmental modifications, and a psychosocial evaluation. Evaluating and optimizing any of the residents predisposing conditions and comorbidities can help prevent the development of wounds [9]. Inspecting skin daily during bathing or personal care, as well as scheduled turning and positioning of patients, has been shown to help prevent wounds. Provide support surfaces with special mattresses and overlays to help eliminate friction, shear, and moisture [34]. Minimize pressure over bony prominences. Seats should be padded with air, foam, or gel cushioning and avoid use of donut–shaped devices [9]. Residents at highest risk (those who completely compress a static surface, or have pressure ulcers that fail to heal), should be placed on a dynamic surface [7, 9]. A patient should never be directly placed on the greater trochanter for more than momentary positioning. Use padding (i.e., heel or “bunny” boots, egg crates, heel lifts, suspension devices, etc.) for off-loading of heels and elbows [7, 9]. Patients should have a static support surface such as a foam overlay or gel mattress placed on their standard mattress. A supine patient should be maintained at the lowest head elevation below 30° as tolerated; head elevation ≥30° provides as much pressure as being in a seated position [35]. Repositioning every four hours has been shown to be as effective as two-hour intervals in wound healing, but this repositioning or partial turning does not always remove pressure from the sacrum or heels. Care should be taken to minimize shearing or friction during repositioning. If necessary, lift devices should be used to prevent soft tissue injury. Slow gradual turns should be used in patients with hemodynamic instability [21].

Inadequate hydration and nutrition are predisposing conditions strongly associated with pressure ulcer development [36]. The caloric intake of 30–35 kcal/kg and daily protein intake of 1.2–1.5 g/kg of body weight is recommended for nutritionally compromised patients who either have or are at risk of pressure ulcers [5]. Adequate hydration is provided by 30–35 mL of fluid per kg body weight per day, or 1 mL of fluid per calorie for persons receiving enteral tube feeding [9]. Enteral nutritional support can significantly reduce the risk of developing pressure ulcers in selected patients, by up to 25 % in some studies. The benefits of nutritional support in facilitating wound healing are still debated [37–39]. Use of vitamin C supplementation in wound healing is also disputed. Two well-designed randomized controlled trials compared high dose vitamin C with either low dose vitamin C or placebo, and had contradictory results [40]. (For a more in-depth discussion on nutrition please see the chapter “Weight and Nutrition.”)

In clinical circumstances such as metastatic cancer, multiple organ failure, cachexia, severe vascular compromise and terminal illness, unavoidable wounds may develop [41]. The clinician should judiciously document the reasons why preventive interventions may not be appropriate or feasible, such as frequent repositioning that is causing discomfort or severe pain.

Pressure ulcers are considered to be quality of care indicator in LTC. There are many factors that are responsible for “unavoidable” pressure ulcers. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer is considered to be unavoidable if it developed despite the following interventions.

A pressure ulcer is considered to be avoidable if the facility failed to implement the above interventions. Many LTC patients are either bed or chair-bound, which significantly limits mobility and places them at risk for pressure ulcers. Patients with hemodynamic instability can make turning or repositioning difficult, as they may develop bradycardia, hypotension or hypoxemia with minimal body movement. In addition, some patients are comfortable in a particular position so they move themselves back into that same position after being turned. Vasoconstrictive medications to increase low blood pressure can predispose to ischemia and increase pressure ulcer risk. When an advanced directive for health care states that artificial nutrition and hydration are not to be used, this can put the patient at risk for malnutrition and ulcer development. Refusal of care is a common issue, especially in patients who are confused and cognitively compromised, and can significantly frustrate the staff who are attempting to offload tissue pressure. Medical device–related pressure ulcers can occur, if they are applied before the development of edema [21].

AMDA—The Society for Post-Acute and Long Term Care Medicine follows the guidelines set forth by the National Pressure Ulcer Advisory Panel (NPUAP) that define, classify and stage pressure ulcers as summarized in Table 2. Staging is based on the extent of observable tissue damage [42]. The latest version of the these guidelines describe stages I–IV along with two adjunctive terms, “ suspected deep tissue injury ” and “unstageable” utilized to more accurately classify these wounds (see website http://​www.​npuap.​org). Reverse staging should not be used. For example, a lesion may be referred to as a, “healing stage IV” but it cannot be described as progressing from a stage IV to a stage III. If a Stage IV pressure ulcer reopens at the same anatomical site, it is always considered as stage IV. An ulcer covered by eschar should be categorized as a Stage IV until the eschar has been debrided. Staging cannot be used for mucosal pressure ulcers [9].