Healthy Skin Magazine - Volume 8 Issue 2

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VOLUME 8, ISSUE 2
Free Webinars Improving Quality of Care Based on CMS Guidelines
New Techniques for Pressure Ulcer Prevention,

Hand Hygiene and CAUTI Prevention
Free CE Inside!
Volume 8, Issue 2
PRESSURE ULCER PREVENTION IN LONG-TERM CARE
Learn more about continuous quality improvement for the prevention of avoidable pres-
sure ulcers and F-Tag 314 citations, factors leading to pressure ulcers in long-term care
facilities and comprehensive pressure ulcer prevention strategies and solutions.
JUNE
3rd 12:00 pm - 1:00 pm
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AUGUST
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SEPTEMBER
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9th 1:00 pm - 2:00 pm
WOUND
Photography
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HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES
As the number one defense against healthcare-acquired conditions, hand hygiene plays Choosing
HEALTHY SKIN
an important role in the prevention of infections. Learn how hospitals and healthcare
facilities are combining best-in-class products and education to achieve hand hygiene Nutritional
Supplements
compliance while dramatically improving the skin condition of healthcare workers.
JUNE J U LY AUGUST SEPTEMBER

14th 11:00 am - 12:00 pm 8th 11:00 am - 12:00 pm 17th 2:00 pm - 3:00 pm 2nd 11:00 am - 12:00 pm
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INNOVATION IN THE PREVENTION OF CAUTI RESULTS
Join your colleagues from around the country to learn more about strategies to prevent
& Winners
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Urinar y Continence Assessment Forms & Tools

Join the team!
HEALTHY SKIN URINARY CONTINENCE ASSESSMENT & IMPLEMENTATION FORM
3. Evaluate for Behavioral Program

What is the MDS Score on B.4 (Cognitive skills for daily decision-making)?
If 0, 1 If 2, 3
What is MDS score on G1I a? Prompted Voiding or Scheduled Voiding
(ADL Self-Performance / Toilet Use)
Residents with the following conditions could still benefit from par-
ticipating in a prompted or scheduled voiding program:
If 0, 1 If 0, 1, 2, 3, 4 • Those who cannot feel “urge” to urinate
Pelvic Floor Rehab Prompted Voiding • Agitated or disoriented residents
Bladder Rehab Scheduled Voiding • Bedridden residents or those with mobility limitations
Based on above, the resident may be a candidate for ______________________________
Resident is not a candidate for a bladder program due to: ❏ Indwelling catheter ❏ Confusion/dementia Other ___________________
4. Catheterization
Catheter — Type __________________________________ Size: ____________________________
Medical Justifications:
■ Urinary retention that cannot be treated medically or surgically, related to:

• Post void residual volume over 200 ml
When it comes to hot • Inability to manage retention/incontinence with intermittent catheterization
topics in long-term care, • Persistent overflow incontinence
you’re the experts! • Symptomatic infections

• Renal dysfunction
■ Contamination of stage III or IV pressure ulcers with urine which impeded healing.
You, our readers, are on the front lines of everything that for writers and contributors. Whether youʼd like to try your
happens in the healthcare industry – and we want to hear hand at writing or offer suggestions for future articles, we ■ Terminal illness/severe impairments – which makes positing/changing uncomfortable or associated with intractable pain.
from you! Have you ever wished you could write an want to hear what you have to say! You never know – the
article that would be published in a large-circulation next time you open an issue of Healthy Skin, it might be
Notes:
magazine? Nowʼs your chance. Healthy Skin is looking to read your own article!
Contact us at healthyskin@medline.com to learn more!
Content Key
Weʼve coded the articles and information in this magazine to indicate which national quality initiatives
they pertain to. Throughout the publication, when you see these icons youʼll know immediately that
the subject matter on that page relates to one or more of the following national initiatives:
• QIO – Utilization and Quality Control Peer Review Organization
• Advancing Excellence in Americaʼs Nursing Homes
Weʼve tried to include content that clarifies the initiatives or gives you ideas and tools for implement-
ing their recommendations. For a summary of each of the above initiatives, see Pages 8 and 9.
Improving Quality of Care Based on CMS Guidelines 111
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HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines
Editor Survey Readiness

Sue MacInnes, RD, LD
45 Urinary Incontinence Assessment: A Very Good Place to Start
Clinical Editor 83 Mount Baker Care Center: Proactive Quality Assurance Measures
Margaret Falconio-West, BSN, RN, Help Improve Resident and Family Member Satisfaction
APN/CNS, CWOCN, DAPWCA
Prevention
Managing Editor
Alecia Cooper, RN, BS, MBA, CNOR 18 Editorial: Shedding Light on Pressure Ulcers and the CMS
Page 10
Hospital-Acquired Conditions (HAC) Policy
Senior Writer 62 The CNO Perspective: What the Board Needs to Know About
Carla Esser Lake
Pressure Ulcer Prevention
Creative Director 66 Announcing New Online Skin & Risk Assessment Competency
Mike Gotti
Treatment
Clinical Team
10 Why Wet to Dry?
Clay Collins, BSN, RN, CWOCN, CFCN,
CWS, DAPWCA
24 A Picture Can Be Worth a Thousand Words
Lorri Downs, BSN, RN, MS, CIC
32 What Type of Wound Is It? Page 20
Cynthia Fleck, BSN,MBA, RN, CWS, DNC,
34 Caring for the Oncology Patientʼs Skin
CFCN, DAPWCA, FCCWS 39 EPUAP/NPUAP Publish New Pressure Ulcer Guidelines for
Joyce Norman, BSN, RN, CWOCN, Palliative Care
DAPWCA 68 Nutritional Supplements: What Approach is Best for Your Resident?
Kim Kehoe, BSN, RN, CWOCN, DAPWCA
Elizabeth OʼConnell-Gifford, BSN, MBA, RN, Special Features
CWOCN, DAPWCA
5 The Survey Results Are In!
Jackie Todd, RN, CWCN, DAPWCA
20 The Future is Now for New Learning Technologies
Connie Yuska, RN, MS, CORLN Page 56
50 Ten Tips for Bathing the Uncooperative Resident
56 Six Sticky Wickets That Commonly Occur in Wound Care Lawsuits
Wound Care Advisory Board
76 Preparing Your Organization for Color-by-Discipline Uniforms
Mary Brennan, MBA, RN, CWON
99 Introducing Deb! Starring in “The Pink Glove Dance”
Zemira M. Cerny, BS, RN, CWS
Patricia Coutts, RN
Regular Features
Cindy Felty, MSN, RN, CNP, CWS
8 Two Important Initiatives for Improving Quality of Care
Evonne Fowler, MSN, RN, CNS, CWOCN
51 Hotline Hot Topic: Incontinence Care
Lynne Grant, MS, RN, CWOCN
Diane Krasner, PhD, RN, CWCN, CWS, Page 66
BCLNC, FAAN Caring for Yourself
Dea J. Kent, MSN, RN, NP-C, CWOCN 90 Win-Win Negotiation: How to Get More of What You Want
Andrea McIntosh, BSN, RN, APN, CWOCN 100 Healthy Eating: Syrian Salad
Linda Neiswender, BSN, RN, CPN
Laurie Sparks, BSN, RN,CWOCN Forms & Tools
Lynne Whitney-Caglia, MSN, RN, CNS, 103 Bilingual Application Guide – Adult Brief
CWOCN 105 Reducing Pressure Ulcers – for CNAs
Laurel Wiersema-Bryant, RN, ANP, BC 108 Wound Photography Validation Checklist
Linda Woodward, BSN, RN, OCN, CWOCN 109 Photography Consent Form Page 90
Deborah Zaricor, RN, CWOCN 110 Urinary Continence Assessment & Implementation Form
About Medline Meeting the highest level of national and international quality standards, Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more is FDA QSR compliant and ISO 13485 certified. Medline serves on major
than 100,000 products to hospitals, extended care facilities, surgery centers, industry quality committees to develop guidelines and standards for medical
home care dealers and agencies and other markets. Medline has more than 800 product use including the FDA Midwest Steering Committee, AAMI Steriliza-
dedicated sales representatives nationwide to support its broad product line and tion and Packaging Committee and various ASTM committees. For more
cost management services. information on Medline, visit our Web site, www.medline.com.
©2010 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

003-056_65528_MedCal:Layout 1 5/5/10 11:15 AM Page 4
HEALTHY SKIN Letter from the Editor
Dear Reader,
At 112 pages, this is our largest and most fact-filled Adventist La Grange for her winning response on how
edition of Healthy Skin ever! The truth is I just couldn’t her facility implemented innovative initiatives that made
cut anymore. There was so much powerful information, a significant impact on quality and patient/resident care.
so many new materials, technology and ideas. Take a look at Kathy’s submission on page 6.
Not only is it bigger … we’re also printing more copies. And, then there was … the rest of the survey, where we
Why? Because we ran out of the last edition early, and asked you about technology. Who had an iPhone, a
we didn’t want that to happen this time. Our readership Blackberry, an iPod, a computer…we asked because
keeps increasing. we had a hunch that regardless of the year we were
born, all of us are beginning to adapt to new ways to
Here’s what we have in store for you…
First, I’d like to share with you the results of the survey
in our last issue. (See opposite page.) One of the things
communicate and learn.
For that reason, our first announcement is that we are

“
There are many
ways to learn,
and we want you
I thought you’d find interesting is the diversity of our so proud to launch our brand new iPhone app for Med-
readers: 40% come from long-term care, 37% from line University. Now you can listen to courses, watch
to have access to
acute care and 14% from home health and hospice.
Our survey respondents included directors of nursing,
wound care nurses, staff nurses, clinical educators,
live videos and take CE tests on your iPhone or iPod
Touch. All for FREE! Now how cool is that? And, if that’s
not enough, by mid-June we will have Medline Univer-
”
all of them!
risk/quality managers, LPNs, nursing aides and nurse sity available for the iPad as well. So, there are many
managers. The top three priorities you are concerned ways to learn, and we want you to have access to all
with are: 1. skin and wound care, 2. staff education and of them!
3. pressure ulcer prevention, which is why we start this
edition with an article on page 10 entitled “Why Wet to Best Regards,
Dry?” It may be old school, but it is still happening.
Next, along with the survey submission, we asked our Sue MacInnes, RD, LD
readers to share successes by responding to a brief Editor
essay question. I‘d like to recognize Kathy Cook from
ON THE COVER
Chief Marketing Officer
Sue MacInnes and Director
of e-Business Jignesh Thakkar
introduce the all-new Medline
University iPhone app at the
2010 National Meeting in
Houston, Tex.
4 Healthy Skin
Special Feature
The Survey Results Are In!

Thank you to everyone who took the time to complete the Medline Healthcare Survey
in the last issue of Healthy Skin.
We are pleased to report that everyone who completed the survey will be receiving our new
“Deb” doll for free.
In her Medline Generation Pink Gloves, pink bouffant cap and scrubs, Deb energetically raises
awareness for breast cancer and the “Together We Can Save Lives Through Early Detection”
campaign. To learn more, visit www.medline.com/dolls.
Where you work Average amount of time 16 minutes

Nursing home or long-term 40% spent on skin tears during
care facility new employee orientation
Hospital 37%
Home health/hospice 14% Pressure Ulcers
Other 9% Average pressure ulcer incidence 4.6%
What you do Your biggest barriers to pressure

Wound care nurse 34% ulcer prevention
Staff nurse 18% Lack of staff compliance 25%
Director of nursing (DON) 13% Proper patient or resident positioning 19%
All other positions 35% Lack of staff education 19%
Your top three priorities Organizations involved 27%

1. Skin and wound care 34% in a lawsuit regarding Introducing Deb!
2. Staff education 33% pressure ulcers
3. Pressure ulcer prevention 23%
Clinicians personally 10%
Clinical position of most concern involved in a lawsuit
for successful implementation of regarding pressure ulcers
necessary changes at your facility
Aides/technician 42% Technology
Nurse 30% Kinds of technology devices you use
Physician 14% PDA (Blackberry®, Palm®, iPhone®) 32%
Cell phone 87%
Skin Tears iPod®/mp3 35%
Average number of skin tears 10 Computer 93%
at your facility per month
Tur n the page to see the bonus question winners!
Blackberry and Palm are registered trademarks of Research In Motion Limited, iPhone, iPod and iPad are registered trademarks of Apple Inc.
Kindle is a registered trademark of Amazon Technologies, Inc., Sony is a registered trademark of Sony Corporation

HealthySkin16.3-mag:Layout 1 5/4/10 11:20 AM Page 6
Congratulations to our SURVEY WINNERS!

Grand Prize Winner
Our grand prize winner will receive an engraved plaque and the entire
Medline Doll Collection, which includes eight dolls in all. Our four other When we hire any nursing staff, we do one
winners will receive the entire Medline doll collection. hour on overall wound issues, prevention, off
loading, positioning and treatments. For the
licensed staff we include a video on wound
vac, and a more detailed educational program
that covers all of the above including wound
rounds, the usual products we use, and how
to measure, document and apply the dressing
supplies. We also have a quarterly hands-on
inservice with dressings, learning with pictures
and bringing in sales reps for the products we
use. We give each new physician our protocols
to read so they understand what we do as a
facility for wound care. The nurse managers do
the weekly wound rounds and I do education
Winners with rounds to the RNs and LPNs. I play ques-
tion-and-answer with the NAs on a daily basis,
As part of a pride project I developed One WOCN developed a wound care and they can now actively participate in the
a wound documentation tool. The program within two months for four program to help us with positioning needs and
sheet is a “to do” list of important branches of our home health company. the individuals’ likes and dislikes as far as how
documentation which should be done This program incorporated all staff in
when a patient has a wound. This their treatments are going. When we discharge
the prevention and management of
includes patient outcomes, nutrition wound patients. She created unique residents to home with home nursing services,
consults, and wound nurse consult, if PowerPoint presentations to “reach” we do education with caregivers who will be
necessary. Since this sheet has been her audiences. Her wound program doing the treatment, and then have them
implemented on all the units, docu- begins with the liaison in the field prior demonstrate for us so we know they know
mentation regarding wounds has to admission, and continues until the how and why they are doing the treatment.
improved. With nurses being more patient is healed. This approach has
aware of their patients’ needs who made everyone feel empowered and
We also give education sheets with signs
have wounds, they will be able to take accountable, creating a huge cost and symptoms of infection, hand hygiene,
better care of the patients. If a patient savings for the company. The real pay- and for diabetics, the signs and symptoms
is transferred from one unit to another, off, however, does not lie in the money of hypo/hyperglycemia.
the sheet moves with the patient so saved, but in the lives impacted.
no information is missed with the Kathy Cook, MSN RN APN CWOCN
transfer. With time, we hope to have Michelle Fritze, RN Adventist La Grange
100% compliance with the new tool Evergreen HealthCare Center La Grange, IL
ensuring patients get the most com- Stafford Springs, CT
plete and up-to-date treatments.
Samantha Conha, BS, RN Our Skin School three times a year We currently utilize the CAP program
Exeter Hospital has saved many wounds. It generates through our company. It stands for C –
Exeter, NH questions regarding anatomy of wound Cleanse the skin, A – Apply moisture
healing, VAC dressings, ostomy care, barrier ointment, P – Pressure relief.
staging of pressure ulcers, formularies We place baseball CAP stickers on
and "tips" to nurses. Have our out- doors of those residents who score 10
comes improved? YES! Nurses are or below on Norton Scale or who have
more confident, thus taking charge actual breakdown to alert staff that
to tackle all dressing changes. these residents have potential for skin
breakdown.
Helena Jerinsky, RN
Delray Medical Center, Kay Grond, LPN, WCC
Delray Beach, FL Twin Falls Care Center
Healthy Skin
Buhl, ID
6
AHCA/NCAL CONGRESSIONAL BRIEFING

HYATT REGENCY WASHINGTON ON CAPITOL HILL
te
The American Health Care Association (AHCA) and the National
Da Center for Assisted Living (NCAL) are pleased to invite you to
e the our Congressional Briefing, June 8-9, 2010, in Washington, D.C.
S Jun av 9 , 2 010
e 8-
Accommodations for this event will be at the beautiful and
convenient Hyatt Regency Washington on Capitol Hill, a few
short blocks to congressional offices.
We look forward to seeing you there!
To register for Congressional Briefing visit: cb.ahcancal.org

For more information, email: ongressionalbriefing@ahca.org
Additional questions? Please call (202) 842-4444
Sponsored by
Two Important National Initiatives

for Improving Quality of Care
Achieving better outcomes starts with an understanding of current quality
of care initiatives. Hereʼs what you need to know about national projects and
policies that are driving changes in nursing home and home health care.
QIO Utilization and Quality Control Peer Review Organization

1 9th Round Statement of Work
Origin: The QIO Statement of Work is based upon Part B of the Title XI of the Social Security Act. The Medicare-funded “Ninth
Scope of Work” plan became effective August 1, 2008 and is a three-year work plan.
Purpose: To carry out statutorily mandated review activities, such as:
• Reviewing the quality of care provided to beneficiaries;
• Reviewing beneficiary appeals of certain provider notices;
• Reviewing potential anti-dumping cases; and
• Implementing quality improvement activities as a result of case review activities.
Goal: In the 9th SOW, the QIO Program has been redesigned with a framework for accountability and also in content. The
content now consists of four themes with the goal to help providers, both in long-term care and acute-care facilities,
prevent illness, decrease harm to patients and reduce waste in health care.
Of note: QIOs will be required to help Medicare promote three overarching themes: adopt value-driven healthcare,
support the adoption and use of health information technology and reduce health disparities in their communities.
Under the direction of the Centers for Medicare & Medicaid Services (CMS), the QIO Program consists of a national
network of 53 QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico and the Virgin Islands.
Quality Improvement Organization Program’s 9th Scope of Work Theme

The official Executive Summaries for the 9th SOW Theme are available at:
http://providers.ipro.org/index/9SOW_summaries
2 Advancing Excellence in America’s Nursing Homes
Origin: A coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing home
residents and staff. The coalition has continued the campaign beyond its first-round end of August 25, 2008 for an
additional 2 years (until September 26, 2010).
Purpose: A coalition consisting of the Centers for Medicare & Medicaid Services (CMS), organizations representing providers,
consumers and government that developed a grassroots campaign to build on and complement the work of existing
quality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.
Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalition
has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction
surveys into continuing quality improvements and increase staff retention to allow for better, more consistent
care for nursing home residents.
Participating providers will commit to focusing on at least three of the eight measurable goals, including at least one clinical goal and
one operational process goal. Current participants may choose to continue with the same goals, add additional goals or change goals
for the next two-year campaign.
Advancing Excellence
The coalition is meeting to consider the following additions for the next two-year campaign:
1. Improving immunizations as a clinical goal
2. Including target setting in all goals
3. Changes to the order in which the goals are presented
8 Healthy Skin
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Regular Feature
The 9th Scope of Work Content Themes
Theme #1: Beneficiary Protection Activities will focus on Theme #4: Prevention Activities will focus on nine Tasks:
nine Tasks: 1. Recruiting participating practices
1. Case reviews 2. Identifying the pool of non-participating practices
2. Quality improvement activities (QIAs) 3. Promoting care management processes for preventive services
3. Alternative dispute resolution (ADR) using EHRs
4. Sanction activities 4. Completing assessments of care processes
5. Physician acknowledgement monitoring 5. Assisting with data submissions
6. Collaboration with other CMS contractors 6. Monitoring statewide rates (mammograms, CRC screens, influenza
7. Promoting transparency through reporting and pneumococcal immunizations)
8. Quality data reporting 7. Administering an assessment of care practices
9. Communication (education and information) 8. Producing an annual report of statewide trends, showing baseline
and rates
Theme #2: Patient Pathways/Care Transitions Activities 9. Submitting plans to optimize performance at 18 months
will focus on three Tasks:
1. Community and provider selection and recruitment There will be two periods of evaluation under the 9th SOW. The first
2. Interventions evaluation will focus on the QIO's work in three Theme areas (Care
3. Monitoring Transitions, Patient Safety and Prevention) and will occur at the end
of 18 months. The second evaluation will examine the QIO's perform-
Theme #3: Patient Safety Activities will focus on six ance on Tasks within all Theme areas (Beneficiary Protection, Care
primary Topics: Transitions, Patient Safety and Prevention). The second evaluation will
1. Reducing rates of health care-associated methicillin-resistant take place at the end of the 28th month of the contract term and will be
Staphylococcus aureus (MRSA) infections based on the most recent data available to CMS. The performance
2. Reducing rates of pressure ulcers in nursing homes and hospitals results of the evaluation at both time periods will be used to determine
3. Reducing rates of physical restraints in nursing homes the performance on the overall contract.
4. Improving inpatient surgical safety and heart failure treatment
in hospitals Focus for the 9th Scope of Work
5. Improving drug safety – Move away from projects that are “siloed” in specific care settings
6. Providing quality improvement technical assistance to nursing – Focused activities for providers most in need
homes in need – New emphasis on senior leadership (CEOs, BODs) involvement
in facility quality improvement programs
Clinical and Operational/Process Goals
Clinical Goals: Goal Actual Goal 5: Establishing individual targets for > 90% 36.5%
Goal 1: Reducing high-risk pressure ulcers < 10% 11% improving quality
Goal 2: Reducing the use of daily < 5% 3% Goal 6: Assessing resident and family 22.5%
physical restraints satisfaction with quality of care
Goal 3: Improving pain management for < 4% 3% Goal 7: Increasing staff retention 13.9%
longer-term nursing home residents Goal 8: Improving consistent assignment 26.6%
Goal 4: Improving pain management for < 15% 19% of nursing home staff so that
short-stay, post-acute nursing residents receive care from the
home residents same caregivers
Operational/Process Goals: Goal Actual
Trends in Goal Selection

Each nursing home participating in Advancing Excellence selects a minimum of three goals (outlined above).
The goals – and the percentage of participating nursing homes that have selected them – are listed below.
Participating nursing homes: 7,481

Goal 1: 70.9% Goal 5: 32.1%
Percentage of participating nursing homes:* 47.6%
Goal 2: 45.3% Goal 6: 62.8% Participating consumers: 2,233
Goal 3: 54.2% Goal 7: 41.2%
Goal 4: 39.6% Goal 8: 31.3% Average number of goals per
nursing home: 3.8
Visit this Web site to view progress by state!
www.nhqualitycampaign.org/star_index.aspx?controls=states_map
*Based on the latest available count of Medicare/Medicaid nursing homes

Journal of the American College of Certified Wound Specialists (2009) 1, 109–113
‘‘Why Wet to Dry’’?

Cynthia A. Fleck, BSN, MBA, RN, ET/WOCN, CWS, DNC, CFCN, FACCWS
Prior to the 1960s, clinicians

commonly believed the perfect
wound healing environment was
dry and dressings simply plugged
and concealed ulcers. However,
research in recent decades has
confirmed that a moist wound
environment where dressings
have the opportunity to interact
with the wound helped promote
healing and reduced the risk of
pain and infection while increas-
ing outcomes.
10 Healthy Skin
Treatment
Let’s begin with a quick quiz:

The following is true about wet-to-dry dressings:
a. They are appropriate only for mechanical debridement.
b. They can cause pain and suffering to the patient.
c. Each dressing change and wound bed disturbance
causes hypoxia, vasoconstriction, cooling,
and destruction.
d. Removal of the dried dressing from the wound
disperses significant bacteria into the air.
e. All of the above.
If you answered ‘‘All of the above,’’ you are correct. Why, dressings come at a high price. The most common reason
then, are the majority of wounds dressed with this archaic, is the perception that gauze is a ‘‘one size fits all’’ modality
barbaric treatment modality? Let’s uncover the issues sur- that is readily available and inexpensive. In addition, these
rounding moist gauze and wet-to-dry ‘‘therapy,’’the worst dressings have been used throughout history since the
oxymoron in our wound care vocabulary. practice is propagated in medical schools and surgical
training. 2 There is also evidence that they are used
Historical Use of Gauze inappropriately.2 Recent journal articles and texts, as well
Through World War I, the task of changing dressings was as expert opinion, support the principle of moist wound
in the domain of physicians and medical students. In the healing, but in practice the use of gauze, predominantly as
1930s, caring for wounds was passed over to experienced a wet-to-dry dressing, does not guarantee a moist wound
nurses and became recognized as part of a nurses’ scope environment.3
of practice. For the next 40 to 50 years, the mainstays of
wound coverings and fillers were gauze, cotton wool pads, Wet-to-dry dressings are described in the literature as a
impregnated gauze, absorbent cotton, and adhesive pads. means of mechanical debridement.4 Debridement is the
The 1960s saw the start of a change in dressings and the mainstay of wound bed preparation since devitalized
philosophy of their use. However, the practice of using material harbors bacteria, delays healing, and increases the
moist saline-soaked gauze and wet-to-dry saline gauze is risk of infection.5 However, it is the opinion of this author
still widely utilized. This is an outdated tradition that persists and others that wet-to-dry or moist gauze does not consti-
despite mounting evidence against it. tute advanced wound care or advanced therapy. Granted,
wet-to-dry gauze is a form of nonselective debridement;
Gauze Dressings however, it is painful if the patient is sensate and can
Gauze dressings can be dry woven or nonwoven materials, produce numerous negative outcomes. Gauze dressings
sponges, and wraps with varying degrees of absorbency, are not the best wound care choice for the patient, the
based on design. Fabric composition may include cotton, caregiver, or the health care system and facility. Gauze
polyester, or rayon. They are available sterile or nonsterile, dressings do not support optimal granulation and healing
in bulk, and with or without adhesive border. The gauze and are more labor intensive than advanced dressings such
may be impregnated with other products, such as hydrogel as polyacrylates, transparent films, hydrocolloids, alginates,
(to hydrate) or sodium chloride (to absorb and draw). hydrogels, and foams. Therefore, these archaic regimes
should be abandoned since they are not considered stan-
Wet-to-Dry and Moist Gauze dard of care. The previous Agency for Healthcare Research
In the United States, wet-to-dry and gauze dressings are and Quality (AHRQ), formerly the Agency for Health Care
still the most commonly used primary dressing substance.1 Policy and Research (AHCPR), in its Clinical Practice Guide-
Reasons for the persistence of gauze and saline as wound lines for Treatment of Pressure Ulcers,6 supported the use
management mainstays include lack of knowledge on the of wet-to-dry dressings for debridement only by maintain-
part of physicians and other clinicians of advanced dressing that their use is backed by expert opinion (rated as C on
ings and how they work, confusion due to the plethora of their hierarchy of evidence).7
advanced products, and the incorrect view that advanced

Changing Philosophy cept of passive dressings began to change. Dressings were

Early preclinical and clinical research in the 1960s started to becoming active in their role of changing the wound milieu
define the idea of moist wound healing and the benefit in in the healing process. The advent of growth factors and
optimizing wound healing. Preserving an optimally moist other biosynthetics such as collagen began the movement
wound bed, homeostatic temperature, and occlusion have to interactive dressings.
been shown to produce better outcomes than practices
that allow wounds to dry out.7-19 The theory that moist Today, research and development is being focused on the
wound care provides for better outcomes began to receive cellular level. New understanding of interactions of the cel-
serious consideration in the late 1970s and 1980s. Prior to lular components within the chronic wound environment
this time, drying of the wound was accepted and accom- and of ways interactive dressings can alter the wound
plished by several mechanisms: the use of povidone iodine environment is putting dressing technology on the cutting
as a drying agent, heat lamps, wet-to-dry dressings, and edge. What is next may be limited only by our understand-
exposure of the open wound to air.10 Transparent film dressing of how the body changes from normal healing of an
ings and hydrocolloids were the first widely used products acute wound to healing of a chronic wound, our techno-
that addressed moisture retention. Throughout the 1980s logical ability to create products, and our imagination about
and early 1990s, there was an explosion in the realm of how to get there.
dressing products. Alginates, hydrogels, and foams
appeared on the market in a wide variety of dressings and Guidelines
topicals. Antimicrobials were beginning to become more The Centers for Medicare and Medicaid Services Guidance
sophisticated by providing time-released delivery systems to Surveyors in long-term care states that the use of wet-
that allowed longer wear time and cost savings. The con- to-dry dressing may be appropriate in limited circumstances,
12 Healthy Skin
but repeated use may damage healthy granulation tissue or adherence.17 Furthermore, wet-to-dry is a nonselective
in healing ulcers and may lead to excessive bleeding and form of mechanical debridement that causes tissue
increased resident pain.11,12 In addition, the American Medical destruction and injury at each dressing change, which
Director’s Pressure Ulcer Guidelines state that wet-to-dry ultimately delays healing.
dressings are not recommended because they adhere to
vital tissue as well as eschar, removing tissue nonselectively As saline evaporates, it becomes hypertonic, and fluid from
when the dry dressing is removed, and tend to be painful.13 the wound is then drawn into the dressing, promoting des-
iccation of the tissue. As the wound dries, cell migration
Evidence and proliferation are impeded.18 Then, the dried dressing
Some problematic issues with wet-to-dry dressings include removal disperses significant amounts of bacteria into
an increased chance of external contamination and infec- the air.19
tion, as well as cross-contamination because gauze dress-
ings do not present any physical barrier to the entry of Armstrong and Price discovered that many physicians
bacteria, which can travel through 64 layers of gauze.14 Fre- would prescribe various gauze dressings, including wet-to
quent (3 or 4 times daily) dressing changes lead to a drop -dry, rather than advanced modalities such as alginates,
in wound temperature, causing vasoconstriction and foams, hydrocolloids, and hydrogels. The research entailed
decrease in blood perfusion. This further drastically impairs a questionnaire sent to 127 general surgeons and achieved
the ability of oxygen to clear bacteria from the wound, lead- a response rate greater than 50%. Gauze dressings were
ing to an increase in tissue infectability. Each time the dress- overwhelmingly prescribed over the alternatives for all
ing is changed, cooling and destruction of the wound wounds except for venous leg ulcers. Almost half the
microenvironment lead to hypoxia, which impairs leukocyte respondents selected wet-to-dry dressings as their choice
mobility and phagocytic efficiency.15 Wet-to-dry dressings for open surgical wounds that are left open to heal by sec-
do little to impede fluid evaporation and do not provide ondary intension. The data also showed that although 75%
moist wound healing unless kept continuously wet. of the respondents had access to the advanced therapies,
Wet-to-dry dressings also prolong the inflammatory they did not use them.20
phase of wound healing, counterproductive to all efforts
at wound closure.16 Ovington describes gauze as the most widely used wound
care dressing and says it may be erroneously considered a
Wet-to-dry dressings are cost prohibitive secondary to standard of care.2 Her article comments that wet-to-dry and
caregiver time and frequency of change, as licensed wet-to-moist are frequently used in clinical practice in a
nurses’ salaries and benefits tend to be one of the highest fashion that makes them interchangeable. She describes
expenses for a facility. Wet-to-dry is a painful and traumatic hampered healing due to local tissue cooling, disruption of
dressing that can cause substantial patient discomfort and angiogenesis by dressing removal, and increased infection
wound bed disturbance as well as poor patient compliance risk from frequent dressing changes, strike through and
Continued on page 15

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they won’t stick to the wound bed, reducing patient
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Ringer’s Solution
Wound Debris
Prior to application into the Due to the polyacrylate’s The 24-hour rinsing action Microorganisms
wound, the TenderWet pad higher affinity for proteins rapidly establishes a clean Necrotic Tissue
is activated with Ringer’s than for salts, the absorbent wound bed, allowing for
solution. core simultaneously takes active wound healing to
up and binds wound debris, take place. There is tissue
necrotic tissue and microor- growth, angiogenesis and
ganisms in exchange for cellular migration.
Ringer’s solution.
prolonged inflammation as good reasons to abandon this Another investigator, Coyne, examined the cost–benefit of
‘‘traditional’’ dressing technique.2 Ovington also offers a wet-to-dry compared with another advanced dressing,
cost-effectiveness argument for change. She illustrates the polyacrylate moist wound dressing (TenderWet, Medline
costs of saline and gauze compared with an advanced Industries, Advanced Skin and Wound Care, Mundelein, IL),
dressing (Tielle, Johnson & Johnson Wound Management, in a nationwide, 65-location home care agency (TLC/Staff
Somerville, NJ) over a 4-week period, performed by a home Builders) and was able to realize a 26% savings annually,
health nurse.2 The largest contribution to cost is nursing and pointed out that wet-to-dry treatments cause pain,
time; even with the patient and/or family doing some of the slower healing, and an increased infection rate.24 There are
care, the cost is decreased with the advanced dressing other important considerations in the choice of a dressing,
secondary to fewer dressing changes and better outcomes such as clinical outcome, quality-of-life issues, discomfort,
(less time to closure). disruption of daily routines and how the patient can cope
with daily activities, that can all be addressed by modern
In Capasso and Munro’s research, wet-to-dry dressings products.25 A comparison of wet-to-dry gauze with an
were compared to hydrogel dressings in the home care set- advanced alternative, polyacrylate moist wound and
ting. Although wound healing rates were similar between debriding dressings, is summarized in the Table 1.
the two groups, the cost of wound care was substantially
higher in the wet-to-dry group because of more frequent Polyacrylate Moist Wound
dressing changes and an increase in labor intensiveness and Debridement Dressings
and more frequent home visits.21 This activated absorbent polyacrylate polymer core dress-
ing absorbs large protein molecules (necrotic tissue and
Colwell, Foremen, and Trotter conclude that a semiocclu- bacteria) while irrigating with Ringer’s solution, a physiolog-
sive dressing that had higher hard dollar costs and required ical fluid, creating a ‘‘rinsing effect’’ (see Figure 1). The
less frequent dressing changes provides for faster healing interactive dressing supports both moist wound healing
outcomes and is less expensive to use than wet-to-dry. and autolytic debridement, gently removing dead tissue
This is contrary to the belief that wet-to-dry dressings are from the wound bed while creating an ideal healing envi-
cost-effective.22 ronment. Polyacrylates debride at a mean rate of 38%.34
Research has shown that polyacrylate gel absorbents
In an international survey study, the European Wound Man- debride just as well as collagenase does.36 Recent research
agement Association illustrated that gauze is most likely to has also shown that the product may be effective in reduc-
cause pain and be the most adherent product in wound ing wound bioburden by interfering with biofilm as well as
care and no longer recommended as best practice. absorbing planktonic or freefloating bacteria.35
Newer products such as hydrogels, hydrofibers, alginates, As the old adage goes, ‘‘What we permit is what we pro-
and soft silicones are least likely to cause pain and were mote!’’ Question this outdated tradition, challenge the old
recommended as a result.23 establishment, demand a more comfortable experience on
behalf of your patients, refuse to participate in outdated

‘‘Wet to dry needs to die!’’
customs, promote advanced wound caring and patient 22. Colwell JC, Foreman MD, Trotter JP: A comparison of the efficacy and cost
effectiveness of two methods of managing pressure ulcers. Decubitus.
advocacy TODAY. Why ‘‘wet-to-dry,’’ I ask. No longer can 1993;6(4):28–36.
we sit idle and complacent when options and evidence are 23. Moffat CJ, Franks PJ, Hollinworth H: Pain at wound dressing changes,
readily available that have shown positive cost and clinical European Wound Management Association Position Document. London, UK:
Medical Education Partnership Ltd.; 2002:2.
outcome. Help me abolish this archaic wound treatment
24. Coyne N: Eliminating wet-to-dry treatments. Remington Report.
once and for all. Repeat after me, ‘‘Wet-to-dry needs to die!’’ September/October 2003;(sup):8–11.
25. Armstrong MH, Price P: Wet-to-Dry gauze dressings: fact and fiction. Wounds.
References 2004;16(2):56–62.
1. Mc Callon ST, Knight CA, Valiulus P, et al: Vacuum-assisted closure versus 26. Bruggisser R: Bacterial and fungal absorption properties of a hydrogel dressing
saline-moistened gauze in the healing of postoperative diabetic foot wounds. with a superabsorbent polymer core. J Wound Care. 2005; 14(9):1–5.
Ostomy/Wound Management. 2000;46(8):28–34. 27. Eming S, Smola H, Hartmann B, et al: The inhibition of matrix metalloproteinase
2. Ovington LG: Hanging wet-to-dry dressings out to dry. Home Health Nurse. activity in chronic wounds by a polyacrylate superabsorber. Biomaterials.
2001;19(8):1–11. 2008;29:2932–940.
3. Bolton LL, Monte K: Moisture and healing beyond the jargon. Ostomy Wound 28. Fleck CA, Chakrararthy D: Continuous debridement options in wound bed
Manage. 2000;46(1A):51S–62. preparation—examining the ‘‘D’’ in the D.I.M.E.S. wound bed preparation model.
4. Bryant RA: Acute and Chronic Wounds. 2nd ed. St. Louis, MO: Mosby; 2000. Adv Skin Wound Care (in press).
5. Kirsner R: Wound bed preparation. Ostomy/Wound Management. 29. Coyne N: Eliminating wet-to-dry treatments. Remington Report.
2003;49(2A):2–3. September/October 2003:8S-11.
6. Bergstrom N, Bennett M, Carlson CE, et al. Treatment of pressure ulcers. 30. Konig M, Vanscheidt W, Augustin M, Kapp H: Enzymatic versus autolytic
Clinical practice guidelines (15). Public Health Service Agency for Health Care debridement of chronic leg ulcers: a prospective radomised trial. J Wound Care.
Policy and Research; 1994. Rockville, MD, Publication # 95-652. 2005;14(7):320–323.
7. Winter GD, Scales JT: Effect of air exposure and occlusion on experimental 31. Paustian C, Stegman MR: Preparing the wound for healing: the effect of
human skin wounds. Nature. 1963;197:91. activated polyacrylate dressing on debridement. Ostomy/Wound Manage.
8. Hinman CD, Maibach HI: Effect of air exposure and occlusion on experimental 2003;49(9):35S–42.
human skin wounds. Nature. 1963;200:377. 32. Lawrence JC, Lilly HA, Kidson A: Wound dressing and airborne dispersal
9. Winter GD: Formation of the scab and the rate of epithelialization of superficial of bacteria. Lancet. 1992;339(8796):807.
wounds in the skin of the young domestic pig. Nature. 1963;193:293–294. 33. Flemister B. The use of a superabsorbent wound dressing pad for interactive
10. Winter GD, Scales JT: The effects of air-drying and dressings on the surface moist wound healing. Paper presented at: 13th Annual Symposium on
of the wound. Nature. 1963;197:91–92. Advanced Wound Care, April 1-4, 2000; Dallas, TX.
11. Department of Health and Human Services, Centers for Medicare and 34. Paustian C, Stegman MR: Preparing the wound bed for healing: The effect of
MedicaidServices. CMS Manual System Pub. 100–007 State Operations activated polyacrylate dressing on debridement. Ostomy/Wound Manage.
Provider Certification. November 12, 2004.Available at http://www.cms. 2003;49(9):34–42.
hhs.gov/manuals/pm_trans/r4SOM.pdf. Date accessed August 2009. 35. Bruggisser R: Bacterial and fungal absorption properties of a hydrogel dressing
12. Fleck CA: New pressure ulcer guidelines. ECPN. January/February with a superabsorbent polymer core. J Wound Care. 2005; 14(9):438–442.
2005;37–42.
13. American Medical Directors Association: Pressure Ulcers in the Long-Term
Care Setting Clinical Practice Guideline. Columbia, MD: American Medical
Directors Association; 2008.
14. Lawrence JC: Dressings and wound infection. Am J Surg. 1994;
167(1A):21S–4.
15. Spear M: Wet-to-dry dressings—evaluating the evidence. Plast Surg Nurs.
2008;28(2):92–95.
16. Ovington LG: Hanging wet-to-dry dressings out to dry. Home Healthcare.
2001;19(8):477–483.
17. Sibbald RG, Williamson D, Orsted HL, et al: Preparing the wound bed:
Debridement, bacterial balance and moisture balance. Ostomy Wound
Manage. 2000;46(11):14–35.
18. Lim JK, Saliba L, Smith MJ, McTavish J, Raine C, Curtin P: Normal saline wound
dressing—Is it really normal? Br J Plast Surg. 2000;53:42–45.
19. Lawrence JC, Lilly HA, Kidson A: Wound dressing and airborne dispersal
of bacteria. Lancet. 1992;339(8796):807.
20. Armstrong MH, Price P: Wet-to-dry dressings: Fact and fiction.
Wounds. 2004;16(4):56–62.
21. Capasso VA, Munro BH: The cost and efficacy of two wound treatments.
AORN journal. 2003;77(5):984–992.
16 Healthy Skin
BRINGING IT HOME TO YOU

More than 1 million Americans receive home health care
services every year.1 Just as every patient is unique, so is
every home health care agency.
That’s why Medline HomeCare is proud to offer innovative

solutions for every segment of your business, designed to
fit your specific needs. We provide:
• Supply management
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• Documented cost savings
To learn more about Medline HomeCare, call us at

1-800-678-7852.
For your free cost-savings analysis, contact your
Reference sales representative or call 1-800-678-7852.
1 The Centers for Disease Control and Prevention. Home Health Care Patients:
Data from the 2000 National Home and Hospice Care Survey. Available at:
www.cdc.gov/nchs/pressroom/04facts/patients.htm. Accessed April 12, 2008.
Prevention
Shedding Light on
Pressure Ulcers
and the CMS Hospital-Acquired Conditions (HAC) Policy
An editorial by wound care expert Diane L. Krasner PhD, RN, CWCN, CWS, MAPWCA, FAAN
First of all, relax. You’re not the only one who’s still confused Although physician/provider documentation is required
about the Centers for Medicare & Medicaid Services (CMS) by CMS, the expertise of wound assessment in hospitals is
Hospital-Acquired Conditions (HAC) Policy. predominantly within nursing. Competence of the provider in
assessment is critical to do an accurate skin assessment.3
Although it’s been over a year and a half since the policy was
implemented, I’m still finding a great deal of misunderstanding If a pressure ulcer is discovered and documented upon
out there among the healthcare professionals I’m meeting at admission, the hospital will receive Medicare reimbursement
various meetings and conferences. to care for the wound. For patients who have no pressure
ulcers, prevention becomes a key focus for clinicians to make
As you may know, effective October 1, 2008, CMS no sure none develop.
longer reimburses hospitals for the care of a list of
high-cost, yet reasonably preventable conditions if the condi- In May 2008, in anticipation of the upcoming implementation of
tions occur while a patient is hospitalized. Stage III and IV pres- the CMS HAC Policy, I joined my colleagues on the Interna-
sure ulcers are the most costly of these conditions, estimated tional Expert Wound Care Advisory Panel for a roundtable dis-
by CMS to be $43,180 per hospital stay.1 The purpose for with- cussion about the policy and ways to help prevent pressure
holding reimbursement is to incentivize hospitals to take greater ulcers.** The outcome of our discussion was a white paper,
care to prevent pressure ulcers and the other conditions “New Opportunities to Improve Pressure Ulcer Prevention And
included in the policy. Treatment: Implications of the CMS Inpatient Hospital Care
Present on Admission (POA) Indicators/Hospital Acquired
As a way to keep track of which patients develop pressure Conditions (HAC) Policy,” which was subsequently published in
ulcers while they are in the hospital, CMS developed the Pres- the Journal of Wound, Ostomy, Continence Nursing.
ent on Admission (POA) Indicator, which identifies if a hospital
patient has a pressure ulcer at the time the order To learn more about the issues we discussed, download
for admission occurs. a free copy of the article at http://www.medline.com/
media-room. As corresponding author for the article, I welcome
Ideally, each patient receives a skin assessment upon admis- related inquiries at dlkrasner@aol.com.
sion, and the provider* 2 determines and documents whether
the patient has any pressure ulcers at that time.
* CMS defines “provider” as “a physician or any qualified healthcare practitioner who 2. Present on Admission (POA) Indicator Reporting by Acute Inpatient Prospective
is legally accountable for establishing the patient’s diagnosis.” Payment System (IPPS) Hospitals. Centers for Medicare & Medicaid Services. Decem-
ber 2007. Available at:
** The work of the International Expert Wound Care Advisory Panel is supported by http://www.cms.hhs.gov/HospitalAcqCond/Downloads/poa_fact_sheet.pdf. Accessed
an educational grant from Medline Industries, Inc. April 28, 2010.
3. Armstrong DG, Ayello EA, Capitulo KL, Fowler E, Krasner DL, Levine JM, et al. New
References
opportunities to improve pressure ulcer prevention and treatment: implications of the
1. Centers for Medicare & Medicaid Services. Medicare Program; Proposed Changes
CMS inpatient hospital care Present on Admission (POA) Indicators/Hospital Acquired
to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates.
Conditions (HAC) Policy. Journal of Wound, Ostomy Continence Nursing.
Federal Register. 2008; 73(84):23550-23553. Available at:
http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf. Accessed April 28, 2010. 2008;35(5):485-492.
18 Healthy Skin
How 4 square inches of Puracol® Plus

changed chronic wound care.
Forever.
Look closely. It’s not a bandage. It’s Puracol Plus ™
MicroScaffold , made entirely of pure native collagen.

™
Chronic wounds tend not to heal when unbalanced levels

of elastase and MMPs (inflammatory enzymes) destroy the
body’s own collagen and growth factors.1
But apply Puracol Plus and help restore nature’s balance.
In vitro studies show that Puracol Plus has the ability
to reduce the levels of elastase and MMPs from
This is Puracol Plus Micro- surrounding fluid.2
Scaffold as seen through an
electron microscope. Its open,
cellular structure allows easy
fibroblast migration.2 The high
strength of the MicroScaffold2
also assists in establishing a
fresh wound bed. Each Puracol package is
a 2-Minute Course in ™
Advanced Wound Care.
1. Schultz GS, Mast BA. Molecular analysis of the environ- ©2010 Medline Industries, Inc.
ment of healing and chronic wounds: Cytokines, proteases, Puracol is a registered trademark of Medline Industries, Inc.
and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F. Medline is a registered trademark of Medline Industries, Inc.
2. Data on file.
The Future
is NOW
for New Learning
Technologies
Don’t get left behind!
Advances in technology have resulted in numerous online Other colleges and universities are catching on to the
educational opportunities that are both free and easy to iPhone as an educational tool as well. Students enrolled in
access. In fact, electronic learning tools have nearly elimi- the undergraduate journalism program at the University of
nated the need to actually attend a class for continuing Missouri are required to have an iPod Touch® or an iPhone
education. Online webinars, e-textbooks and podcasts are to download course material.2 And the Blackboard app is
just a few of the options. And how about iPhone® apps? gaining popularity at many high schools and colleges as a
way to post assignments, grades, documents, discussion
Beginning with the 2008-2009 school year, all incoming boards and anything else associated with a course.3
freshmen at Abilene Christian University in Texas are
required to have an iPhone. Apps are used to turn in home- Posted on wired.com by: Panacea | 12/8/09 | 6:04 pm1
work, look up campus maps and check class schedules The community college where I teach nursing piloted giving
and grades. For classroom participation, there’s even iPods to students a few years ago, with the idea of using
polling software so students can digitally raise their hand to iTunes U. They like being able to replay lectures. I don’t do
answer questions.1 a traditional lecture in class anymore. The students down-
load their lectures. Class time is for interactive assignments
William Rankin, a professor at Abilene Christian, comments, such as care mapping, case studies, and discussion. Stu-
“This is a question of how do we live and learn in the 21st dents still get to ask questions about the iTunes content.
century now that we have these sorts of connections? Grades have been steadily improving over the last 3 years
I think this (the iPhone) is the next platform for education.”1 since I’ve moved to iTunes U. Retention has improved 15%.
20 Healthy Skin
Treatment
Teaching & Learning: THE PRINT AGE Teaching & Learning: THE DIGITAL AGE
Course activity typically focuses on presentation of infor- Course activity typically focuses on students contextualizing,
mation with students contextualizing, practicing or using practicing, or using information with presentation of infor-
information at home. mation occurring at home through media or online access.
The classroom is the primary site of access to course con- Access to course content is augmented by electronic
tent, and access is often “linear” – students cannot typically sources and media, and access is often recursive or
return to previous class presentations. “on-demand,” allowing students to return to content when
and as often as they’d like.
Students and teachers have access to one another prima- In addition to classroom access, students and teachers
rily in the classroom. have access to one another via “virtual” means – online
discussions, e-mail, chat, social networking, etc.
Source: Dr. William Rankin, “Abilene Christian University 2008-09 Mobile-Learning Report.” Available at: http://www.acu.edu/technology/mobilelearning.
References:
1. Chen BX. How the iPhone could reboot education. Wired – Gadget Lab. Available at: http://www.wired.com/gadgetlab/2009/iphone-university-abilene. Accessed March 29, 2010.
2. Dignan L. Apple’s iPod Touch, iPhone as education tool: should universities dictate whether you’re a Mac or PC? Available at: http://blogs.zdnet.com/BTL/?p=17775. Accessed March 29, 2010.
3. The Next Generation of Educational Leadership: A blog for educational leaders who want to learn, share and discuss 21st-century education leadership strategies. March 29, 2009. Available at:
http://nextgeneduleaders.blogspot.com/2009/blackboard-app-for-iphone-great-tool.html. Accessed March 31, 2010.

S!
U RE
AT
FE
W
NE
NG
TI
CI
EX
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Medline University
Introduces ...
iPhone® App
At home, at work or on the go…
earn free CE credits
It’s even easier to maintain licensure and certification
and validate competencies! All Medline University
courses are now available as a free iPhone® and iPod
touch® app that can be downloaded from The
Apple® Store.
As always, you can also access courses online

on your computer and download podcasts to your
MP3 player. New courses and competencies are
more interactive with graphics, sound and animation
to make learning fun.
Nurses Are Getting WIRED

In a recent poll of 762 Medline customers
and subscribers of The OR Connection
and/or Healthy Skin magazine:
• 41 percent were RNs
• 10 percent own an iPhone
Of those who own an iPhone:

• 89 percent said they would download
available content from Medline
• 88 percent have downloaded content
from the iTunes store
• 64 percent were 40 or older
• 30 percent currently use their
iPhone as a reference at work
Visit www.medlineuniversity.com today

and start earning CE credits* – FREE.
* Courses approved for continuing education by the

Florida Board of Nursing and the California Board
of Registered Nursing
©2010 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.
iPhone and iPod Touch are registered trademarks of Apple, Inc.
A PICTURE
CAN BE
WORTH A
THOUSAND
WORDS
24 Healthy Skin
Treatment
The use of photo documentation in wound care

By Elizabeth O’Connell-Gifford, MBA, BSN, RN, ET/CWOCN, DAPWCA
A picture often says more than any number of words possibly could. Think about it.
No matter how poetically you might describe the beautiful scenery from your last
vacation, a photo of that gorgeous mountain view says it all. Similarly, even the most
experienced wound care nurse’s detailed chart notes describing a wound simply do
not deliver the same impact as a color photo.
Whether you are questioning the value of an already established useful complement to the clinical record, they cannot stand
wound photography protocol at your facility or agency, or you alone and should not replace the written word.1
are considering putting one into place, here are some issues to
ponder regarding this beneficial, yet sometimes controversial Documenting progress. Wound photos taken at intervals
practice. during the care process can provide evidence that the wound
was regularly assessed and staged. They can show either a
Why add photography? progression of healing, or at least show how new treatments
Photographing wounds provides many clinical benefits. were introduced to address a non-healing wound.1
Photos provide a visual to accompany the written wound
assessment, they serve to document the wound’s progress According to the National Pressure Ulcer Advisory Panel
over time, they may protect the facility during a lawsuit, improve (NPUAP), photography may offer a more accurate means for
coordination of care among clinicians and serve as a tool for assessment of wound dimensions and wound base over time.
patient and family education. NPUAP also states that rates of healing, and therefore meas-
ures of therapeutic efficacy, are more readily appreciated when
Wound assessment. A comprehensive wound assessment the data are in a visual format.3
and documentation of the findings are essential components
of wound care. In fact, care of a wound, particularly a pressure Legal protection. Wound photography can be beneficial if
ulcer, can be a visual art, often yielding insights beyond those legal issues arise, although opinions vary greatly on this matter,
of a word description.1 As illustrative as they are; however, pho- and some say wound photos can be detrimental in a lawsuit.
tos do have their limitations. For example, they cannot show
factors such as wound odor and warmth.2 In addition, clinical On the positive side, photographs can assist in protecting your
experts agree that although photographs of wounds are a facility from liability for the wound occurring while the person

Venous Wound
Arterial Wound
was under your care. This is a particularly frequent issue with In this case, wound photography, can prove to be highly
pressure ulcers. If a nursing home resident with no wounds or beneficial. Under different circumstances, however, wound
skin injuries is transferred to the hospital, and then returns photographs could inflame a jury and hurt a defendant’s case.4
to the nursing home with a pressure ulcer, each facility often This side of the debate will be covered under the “Issues to
points the finger at the other regarding under whose care the consider” section of this article.
pressure ulcer occurred.
Improving coordination/continuity of care. Again, no mat-
If the nursing home was proactive, however, in documenting ter how thorough a nurse’s written documentation of a wound,
the condition of the skin with photos upon admission and there is some degree of subjective interpretation, which a photo
discharge, it could more easily protect itself from liability. For can mitigate, especially if the reader is unfamiliar with wound-
example, let’s say a nursing home photographs areas of a res- related terms used, such as slough, eschar, granulation tissue,
ident’s body that are prone to pressure ulcers (sacrum, heels, friable tissue or undermining.4 If a nurse includes a wound
elbows) right before the resident is discharged to the hospital. photo with her shift report or documentation right before the
The photos and clinical record are documented with the date, new nurse takes over the patient’s care, the photo, along with
time and a written description, and they show intact, wound- notes in the record, gives a more comprehensive overview of
free skin. the wound. The photo also clearly identifies areas within and
around the wound that require monitoring.
Then, the nursing home takes photos of the same areas of the
resident’s skin as soon as he or she returns from the hospital. After trialing a wound photography program for pressure ulcer
Again, the photos and record are documented with the date, prevention at a tertiary care Level I trauma facility, the facility ex-
time and a written description, and now the photos show red- perienced enhanced communication between nurses during
dened skin with signs of tissue breakdown. Comparing the shift-to-shift report and unit-to-unit transfers. Wound photog-
before and after photos and documentation, it would be diffi- raphy also improved the ability to monitor wound status despite
cult to place blame on the nursing home for the skin injury. different nurses caring for the patient.5
26 Healthy Skin
Patient/resident and family education. Wound photo- Perhaps because of these “tricky” issues surrounding wound
graphs can be especially useful for patient/resident and family photography, the National Pressure Ulcer Advisory Panel
education. Aside from dressing changes, wounds are covered (NPUAP) and the Wound, Ostomy and Continence Nurses
most of the time. If a family member wanted to see a wound, Society (WOCN) neither recommend nor discourage the use of
the dressing would have to be removed, potentially disturbing photography as a documentation tool for pressure ulcers. Both
the granulation tissue. If a photo were available, the nurse could NPUAP and WOCN; however, do agree that facilities should
simply show the family member the chart. maintain written guidelines regarding if and when photography
is to be used.6
For patients or residents with wounds in areas that are difficult
to see, such as on the feet, or obese patients’ pannus injuries, Patient privacy and confidentiality. If you decide to initiate
a photo allows the patient to view a wound he or she other- wound photography at your facility or agency, it is advisable to
wise could not see. Putting a visual picture of the wound in the discuss your decision with your risk manager and legal coun-
residents’ or patients’ mind can be a useful way to motivate sel. Each state has its own rules on photography, and your pol-
them to be compliant with care.1 icy must be consistent with these laws.1
Issues to consider As you develop your wound photography policy, you also will
As beneficial as wound photography can be, it certainly requires want to include a section on patient consent. The Joint Com-
exercising caution concerning litigation, patient privacy and mission on Accreditation of Healthcare Organizations strongly
confidentiality. advises organizations to obtain informed consent before pho-
tographing a patient. The Health Insurance Portability and
Legal concerns. Much the same as wound photography can Accountability Act (HIPAA) guidelines also mandate protection
be helpful in defending a medical malpractice case, it can also of patient privacy through written informed consent.1
put the defendant in a poor light.
The photography consent form, to be signed by the patient or
According to attorney Annemarie Martin-Boyan, photographs legal representative, should state the planned use of the wound
may make the defense attorney’s job more difficult because images, such as monitoring the progress of wound treatment
gruesome photographs tend to arouse the jury’s sympathy for
the plaintiff at the expense of the healthcare team.4
Neuropathic Diabetic Wound
Necrotic Wound

Approximately five million patients in

the United States have chronic wounds,
with 1.5 to 1.8 million new wound
cases added each year.7
and consulting with a wound care specialist. If there is a possi-

bility that the images will be used for educational purposes or
publication in a journal, these intentions also should be visibly
acknowledged in the consent form.2 (See page 109 of this issue
10 STEPS for a sample photography consent form.)
for Infection Control When Other important considerations regarding patient privacy
Photographing Wounds2 include never photographing the patient’s face or other distin-
guishing characteristics such as birthmarks, tattoos or jewelry
1. Place camera with carrying case in a clean area and never altering a photo by adding, adjusting, removing or
separate from the patient and wound supplies. moving anything.2
2. Wash hands and put on exam gloves.
3. Remove the wound dressing, position and drape Maintaining confidentiality of wound photos goes hand in hand
the patient and place a disposable measuring with patient privacy. After taking photos, transfer them to a
tape next to the wound. secure, password-protected computer, and then delete the
images from the camera.
4. Remove and discard gloves.
5. Wash hands again with alcohol-based gel,
Editor’s note: For sample copies of a wound photography compe-
remove camera from the case and place it next tency checklist and a photography consent form, go to the “Forms &
to the patient on a clean surface. Tools” section of this issue.
6. Take the photos, making sure the camera does
References
not touch the patient. Do not wear gloves; 1. Langemo D, Hanson D, Anderson J, Thompson P, Hunter S. Digital wound photogra-
phy: points to practice. Advances in Skin & Wound Care. 2006; 19(7):386-387.
powder from gloves can damage the camera. 2. Buckley KM, Adelson LK, Hess CT. Get the picture! Developing a wound photogra-
7. Put camera back in the clean area, cleaning it phy competency for home care nurses. Journal of Wound, Ostomy and Continence
Nursing. 2005; 32(3):171-177.
with sanitizing wipes before removing it from 3. FAQ: Photography for pressure ulcer documentation. National Pressure Ulcer Advi-
sory Panel website. Available at: http://www.npuap.org/faq.htm. Accessed April 27,
patient area.
2010.
8. Sanitize hands and put on new clean gloves. 4. Calianno CA & Martin-Boyan A. When is it appropriate to photograph a patient’s
wound? Advances in Skin & Wound Care. 2006; 19(7):304-306.
9. Re-dress the wound. 5. Scardillo J, Hanna L, Sigond K, Labarre L, Vaughan C, Maskell-Amirault M, et al. A
picture is worth a thousand words … implementation of a wound photography program
10. Remove and discard gloves; sanitize hands
in surgical and medical intensive care units. Journal of Wound, Ostomy and Continence
and bring camera to docking station to Nursing. 2007; 34(3S):S46.
6. Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, et al. Legal issues in
download photos. the care of pressure ulcer patients: key concepts for healthcare providers. Journal of
Palliative Medicine. 2009; 12(11):995-1008.
7. Buckley KM, Tran BQ, Adelson LK, Agazio JG, Halstead L. The use of digital images
in evaluating home care nurses’ knowledge of wound assessment. Journal of
Wound, Ostomy and Continence Nursing. 2005; 32(5):307-316.
28 Healthy Skin
Guidelines for Wound Photography

General tip Composition
Digital photos are always preferred. • Avoid clutter in the background and clothing or towels
with prints.
Patient selection • Include a ruler with date, length, width and depth of
Approach each patient as if they/their wounds will become a the wound(s) in each photo.
poster/case study. Get in the habit of using good photography • Position the patient in the same manner for each set of
techniques every time to improve your photo outcomes. Make photos to best show consistency as the wound progresses.
time to compose your shot and your patient. • Take the photo from the same angle each time. It’s best
to have the camera pointing perpendicular at the wound
Permission instead of down from the top.
Obtain photo consent, as required by your agency or facility. • Take the photos at the same time of the day to help
with consistency in lighting.
Frequency • To avoid blurry photos, stand firmly with your feet
Photos should be taken on admission, weekly thereafter, and at shoulder width apart and tuck your elbows tight to
wound closure. All efforts should be made to protect patient prevent any shaking.
privacy with regard to HIPAA compliance. • Take a minimum of three shots per wound site at
each visit.
Lighting • Shoot photos from a distance of four feet.
Use natural light (no flash) when possible. Be careful that the • Two-foot closeup – 90% person and 10% background
sun does not wash out the subject or distort the surface tex- • Two-foot with zoom – highlight tissue texture, drainage
ture. If the light source is behind you, make sure your body does • Preview shots taken to ensure pictures are clear
not create a shadow. and visible. Retake if necessary.
Background Additional photos of wound care procedures that highlight

The objective is to showcase the wound on a solid background. dressing removal, amount and absorption of drainage, prod-
Drape the patient in a dark blue or black cloth as it helps to uct performance, wound pre- and post-irrigation, and dressing
absorb the flash and decrease the reflection off the patient’s application steps are all of interest.
skin. Shiny underpads that reflect the flash should also
be avoided.

“A Picture Can Be Worth a Thousand Words –

The Use of Photo Documentation in Wound Care”
True/False 8. Approximately ___ million patients in the United

1. Wound photos can stand alone without States have chronic wounds.
any written documentation in the clinical a. 3
record. T F b. 10
c. 5
2. Polaroid photos are always preferred d. 1
over digital. T F
9. Which of the following is one way to protect a
3. Use natural light (no flash) whenever patient’s or resident’s privacy when taking photos
possible. T F of wounds?
a. Requiring the patient or resident to sign a photo
4. After taking wound photos, transfer them to consent form
a secure, password-protected computer and b. Only taking photos of wounds on the hands or feet
delete them from the camera. T F c. Only showing the photos to the physician
d. None of the above
5. Facilities should maintain written guidelines
regarding if and when photography is to 10. How can wound photography improve
be used. T F coordination of care among clinicians?
a. By improving the ability to monitor wound status
Multiple Choice despite different nurses caring for the patient
6. Which of the following organizations neither b. By clearly identifying areas within and around the
recommends nor discourages the use of photos wound that require monitoring
as a documentation tool for pressure ulcers? c. By giving a more comprehensive overview of
a. The Centers for Medicare & Medicaid the wound
Services (CMS) d. All of the above
b. The National Pressure Ulcer Advisory Panel
(NPUAP)
c. The Wound, Ostomy and Continence Nurses
Society (WOCN)
d. Both b and c
7. Choose the FALSE statement below:

a. Photos serve to document a wound’s progress
over time
b. Wound photos may protect a facility during
a lawsuit
c. It’s important to include the patient’s face in
wound photos Submit your answers at
d. Wound photos can serve as a tool for patient www.medlineuniversity.com
and family education and receive 1 FREE CE credit
Courses approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing.
30 Healthy Skin
Patient Safety is in Your Hands
Epi-clenz™ Gel Instant Hand Sanitizers contain

70% v/v ethyl alcohol to disinfect hands of most
common disease-causing germs. They also contain
aloe vera and vitamin E to care for and soothe the
skin. The Breesia formula is a desirable option
if a mild, pleasant fragrance is preferred.
Be one of the first 1,000 to try a FREE sample of

Epi-clenz. Send your name, facility, address and
Also available in a e-mail to handhygienecompliance@medline.com
foaming formulation.
©2010 Medline Industries, Inc. Medline and Epi-clenz are registered trademarks of Medline Industries, Inc.
WHAT TYPE OF
Wound Appearance
PRESSURE VENOUS
Definition Damage to the skin or underlying struc- Failure of venous valve function in return-
tures as a result of tissue compression and ing blood from the lower extremities to the
inadequate perfusion heart causing venous congestion, leading
to venous hypertension
Location Usually over a bony prominence Gaiter area (ankle to mid calf), often me-
dial malleolus, may be circumferential
Wound Margin Usually circular Irregular shaped
Wound Bed Can have viable or necrotic tissue Usually shallow, can have viable or
necrotic tissue
Wound Size Can be very large or very small Usually large
Exudate Can vary from none to heavy Can vary from none to heavy to general-
ized weeping
Edema Can be localized, usually not seen Generalized edema to lower extremity
Limb Staining Usually not present Usually seen
Ankle Brachial Index (ABI) N/A > 0.8
Pedal Pulses N/A Usually normal, or undetectable due

to edema
Pain Usually, but often undertreated Often in dependent position, with edema
Best Practice • Remove necrotic tissue • Compression

• Maintain optimal moisture • Remove necrotic tissue
• Protect periwound skin • Maintain optimal moisture
• Control bioburden • Protect periwound skin
• Remove pressure • Control bioburden
• Ensure lower extremity moisturization
32 Healthy Skin
Treatment
WOUND IS IT?
Wound Appearance
ARTERIAL NEUROPATHIC /DIABETIC

Wounds caused by ischemia, related to Neuropathy is often associated with dia- Definition
the presence of arterial occlusive disease betes. Wounds result from damage to the
autonomic, sensory or motor nerves and
have an arterial perfusion deficit
Distal aspect of arterial circulation, can be Can be anywhere on the lower extremity, Location
anywhere on the leg (i.e. toes and feet) often on the foot
“Punched out,” well defined borders Similar to arterial, usually with a Wound Margin
callous edge
Pale wound bed, little or no granulation, Similar to arterial, usually with a Wound Bed
necrotic tissue is common callous edge
Can be small, often increases due to lack Often small Wound Size
of arterial perfusion
Minimal to no exudate Similar to arterial Exudate
If present, localized Similar to arterial Edema
Usually not present Similar to arterial Limb Staining
< 0.8 Not reliable, sometimes > 1.0 falsely eval- Ankle Brachial Index (ABI)
< 0.5 - indicates inability to heal uated due to calcification
Usually reduced or absent Not reliable Pedal Pulses
Occurs at rest, nocturnal, or when ex- Due to neuropathy, pain may be absent or Pain
tremity is elevated severe
• If perfusion not adequate, consider • Maintain optimal moisture Best Practice

vascular consult • Control diabetes, if appropriate
• If perfusion is adequate, follow protocol • Repetitive removal of callous
based on wound assessment and
characteristics • Bioburden control and prevention
of systemic infection
• If dry, stable eschar leave intact
• Remove pressure with appropriate
offloading shoe or other appliance

By Linda Woodward BSN, RN, OCN®, CWOCN
As the largest organ of the body, the skin is a reflection of overall health. For individuals
in the oncology setting undergoing chemotherapy, radiation, biotherapy and other forms
of cancer treatment, safe and healthy wound and skin care can be challenging.1
Cutaneous manifestations of internal disease

Some cutaneous diseases are frequently associated with internal diseases. The skin prob-
lem may be inconsequential, but the underlying disease process should be thoroughly
investigated.2 Paraneoplastic syndromes are actually diseases that appear before or con-
currently with an internal malignancy. In some instances the cutaneous changes are
thought to result from the production of hormones, growth factors or antigen-antibody
responses induced by the tumor. Paraneoplastic syndromes are thought to happen when
cancer-fighting antibodies or white blood cells (known as T-cells) mistakenly attack
normal cells in the nervous system.3
Over the past 20 years or so, new antineoplastic treatments have been developed.
Collectively these are known as targeted therapy agents. Many of these agents interfere
34 Healthy Skin
Treatment
with signal transduction, such as epidermal Patients can present with external tumors any time during
growth factor receptor (EGFR) inhibitors. 4 They their cancer treatment. Many times the goal of wound care
are associated with dermatologic complications is palliative, addressing odor management, exudate and
that are usually dose-limiting.5 One such agent can periwound skin. The goal for palliative patients is manag-
cause bullous, blistering and exfoliative skin condi- ing symptoms in order to provide a good quality of life.7
tions, including reported cases of Stevens-Johnson
syndrome or toxic epidermal nycrolysis, which in some Cancer treatment and skin problems
cases can be fatal. Radiotherapy, either internal or external, has a major effect
on the skin. The effects of radiation rapidly divide cells and
External malignant tumors cause cell death. The skin can become erythematous,
Fungating wounds present physical and emotional chal- painful and the patient may experience desquamation
lenges to patients, family members and healthcare resulting in partial and/or full thickness wounds.
providers.6 These lesions may be the result of a primary Chemotherapy can cause hyperpigmentation, hypersensi-
cancer of the skin, metastases of a distant tumor to the tivity and photosensitivity.8
skin or a direct extension of the primary tumor to the skin.
Dressing Suggestions for Fungating Wounds

Pain Management Control of Bleeding Odor Management Exudate Control Peri Wound Skin Mgmt Debridement
Nontraumatic Hemosatic dressings Wound cleansing Wound Skin friendly tapes Autolytic
dressings cleansing
Non-adherent Gentle pressure Antimicrobial Alginates or Wraps Enzymatic
dressings hydrofibers
Gels, creams Charcoal dressings Absorptive Skin preps Polyacrylate
powders
Ointment- Cyclodextrin Wound pouches Sharps
impregnated dressings
Contact layers Foams

or dark pink at the same time.11 Care of patients with PPE

includes application of an emulsion at the start of
chemotherapy and continuing two to three times a day
throughout the course of treatment.
Skin tears. Cancer treatment can “thin” the skin and make
it extremely fragile. Skin tears in the oncology patient are
very common. Older patients and oncology patients are
very vulnerable to skin tears primarily because the epider-
mis thins.12 The first and most widely cited skin tear grad-
ing system, by Payne and Martin (1993), involves grading
the skin tear as a I, II or III.13
Malignant fibrous histiocytoma I Skin tear without tissue loss. The skin
flap can be approximated so that no more
Alopecia. Another common complication of chemother- than 1 mm of dermis is exposed.
apy is alopecia, or hair loss. It is the most common II Skin tear with partial tissue loss.
dermatologic complication caused by chemotherapy.9 III Skin tear with complete tissue loss.
The epidermal flap is absent.
Radiation recall. This refers to the augmentation of
radiotherapy effects. This may appear as dry or moist
desquamation or as erythema and edema. It is an inflam-
matory skin reaction that occurs in a previously irradiated
body part following drug administration.4 Care of irradiated
skin includes promoting cleanliness and hydration, recom-
mending loose fitting clothing, using mild cleansers,
bathing with tepid rather than hot water, and avoiding
petrolatum-only products and those containing alpha
hydroxy acids (AHA). Also, instruct your patients to avoid
silver impregnated dressings and silver wound care oint- Leukemia cutis
ments, as the silver can interfere with the radiation. Advise
patients to inform their radiation oncologist of any wounds, Managing skin reactions to cancer therapy
dressings or creams that they have applied prior to For patients undergoing cancer treatment, the manage-
their treatment.9 ment of skin reactions is an important part of getting
through treatment. Many everyday skincare products con-
Palmar plantar erythrodysesthesia. Palmar plantar tain ingredients that are unhealthy for the cancer patient’s
erythrodysesthesia (PPE) is also called hand-foot syn- skin, which can become sensitive to some of these ingre-
drome or acral erythema. It is an unpleasant or painful feel- dients. The most frequent culprit of adverse reactions
ing in the palms of the hands and the soles of the feet is fragrance. Read labels carefully and follow directions
caused by certain types of chemotherapy.10 Sometimes, exactly. When in doubt, check with your oncologist or
these areas are tender or swollen with tingling or burning dermatologist for product recommendations.
sensations. The skin of the palms and soles often turns red
36 Healthy Skin
Medline Remedy
®
Serious care.
Serious results.
Nosocomial pressure Nosocomial pressure Estimated cost

ulcers reduced by ulcers reduced to zero savings of $6,677.11
50% after 3 months1 after 8 months1 per patient
Independent outcomes research1 was conducted in an acute care facility where,

after implementation of a prevention program, the only additional change during the
reduction period was the focus of improving skin care by using Medline Remedy
products* exclusively, as part of a formal skin care regimen. The results were amazing!
To receive a FREE TRIAL of our effective Remedy skincare

products, contact your Medline representative.
* A silicone-based dermal nourishing emollient (SBDNE)

1. Shannon RJ, Coombs M, et al. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated
skincare regimen. Adv Skin Wound Care, 2009;22:461-7.
©2010 Medline Industries, Inc. Medline and Medline Remedy are registered trademarks of Medline Industries, Inc.
Conclusion
The management of potential skin complications requires
the application of wound healing principles under the care
of a WOC nurse. As with other chronic wounds, goals can
range from healing to palliation and symptom manage-
ment. Collaboration among the oncology nurse, the WOC
nurse and other healthcare providers is valuable to estab-
lish guidelines for the specialized care of oncology patients’
skin issues.15,16
References
1. Woodward L & Haisfield-Wolfe ME. Management of a patient with a malignant
cutaneous tumor. Journal of Wound, Ostomy, Continence Nursing. 2003;30(4):
231-236.
Malignant melanoma 2. Habif T. Clinical Dermatology. St. Louis, MO: Mosby; 2004: 895
3. Paraneoplastic Syndromes Information Page. National Institute of Neurological
Disorders & Stroke. Available at: www.ninds.nih.gov/disorders/paraneoplastic/
Skin Care Tips for Cancer Patients: paraneoplastic.htm. Accessed April 16, 2010.
4. Froiland K. Challenging skin management related to targeted therapy. Wound,
1. Talk to your oncologist or dermatologist regarding Ostomy, Continence Nurse Education Program Lecture at the University of Texas M.
a specific course of anti-cancer therapy. Find out D. Anderson Cancer Center, Houston, TX, May 2009.
5. MedWatch: The FDA Safety Information and Adverse Event Reporting Program.
the integumentary side effects and recommended
Available at: www.fda.gov/medwatch. Accessed April 16, 2010.
treatments.14 6. Bryant R & Nix D. Acute & Chronic Wounds. 3rd ed. St. Louis, MO: Mosby; 2007:
471-489.
2. Check the labels of all topical creams and lotions. 7. The Wound Care Handbook. Mundelein, IL: Medline Industries, Inc.; 2007: 158-160.
Avoid products that contain parabens, lanolin, 8. Groenwald S, Frogge MH, Goodman M, Yarbro CH. Clinical Guide to Cancer
Nursing. 4th ed. Sudbury, MA: Jones & Bartlett; 1998: 203-220.
p-phenylenediamine (PPD) and propylene glycol.
9. Dermatologic Complications of Cancer Therapy. Available at:
These are some of the more frequent skin irritants.10 www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cmed&part=A38915.
Accessed March 2, 2010.
3. Cleanse skin by gently patting it with a mild soap. 1 0. Skin Care Advice for Cancer Patients. Chrysalis Spa & Skin Care Center. Available
Do not scrub the skin. When patients receive at: www.abcn.ca/artman2/publish/Tests_amp_Treatment_52/Skin_care_for_
cancer_patients. Accessed February 26, 2010.
chemotherapy, their platelets and white blood cells
11. Palmar Plantar Erythrodysesthesia. Available at: www.huntsmancancer.org/
are diminished. Overzealous cleansing can cause patientdocs/hci/drug_side-effects/handfoot.html. Accessed March 2, 2010.
skin tears, which can become infected in the 12. Exploring best practice in the management of skin tears in older people. Available
at: http://www.nursingtimes.net/nursing-practice-clinical-research/specialists/wound-
immunocompromised patient.14 care/exploring-best-practice-in-the-management-of-skin-tears-in-older-people/
5000502.article. Accessed April 16, 2010.
4. Use a petrolatum-free lip balm. Drying of lips and
13. Payne RL & Martin ML. Defining and classifying skin tears: need for a common
oral mucous membranes is common during cancer language. Ostomy Wound Management. 1993; 39(5): 16-20, 22-24, 26.
treatment.14 14. Is There Effective Skin Care for Cancer Patients? Available at: http://www.futured-
erm.com/2008/12/19/is-there-effective-skin-care-for cancer-patients. Accessed
5. Remember to use sunscreen. Many cancer drugs February 26, 2010.
15. Woodward L. Wound & skin care in the leukemia & lymphoma patient. (Poster
cause photosensitivity, so sunscreen is necessary
Presentation). Oncology Nursing Society. May 2004.
even on cloudy days.14 16. Woodward L. Effective Management of Externalized Malignant Tumors. (Poster
Presentation). Symposium on Advanced Wound Care. May 2003.
About the author

Linda Woodward is a certified wound, ostomy, continence
nurse at The University of Texas M. D. Anderson Cancer Center
in Houston, Tex.
38 Healthy Skin
Treatment
EPUAP/NPUAP Publish New

Pressure Ulcer Guidelines for
Palliative Care
Dealing with the end of a loved one’s life is difficult enough, uals Receiving Palliative Care,” which is reproduced on the
but when wound and skin care issues are involved, the deci- following pages for your reference. The palliative care
sions about how to manage the patient can be even more perspective is woven throughout, showing how to focus
challenging. The European Pressure Ulcer Advisory Panel treatment decisions on maintaining the patient’s comfort
(EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) in terms of pressure redistribution, nutrition and hydration,
have added a new section on palliative care to their pressure skin care, pain assessment and management and resource
ulcer treatment guide to help clinicians navigate through some assessment.
of these difficult treatment decisions.
Clinicians caring for terminal patients with pressure ulcers will
Pressure Ulcer Treatment: Quick Reference Guide now find this resource tremendously helpful.
includes a section on “Pressure Ulcer Management in Individ-

Pressure Ulcer Management in Individuals Receiving Palliative

Care Patient and Risk Assessment
Assessment
1. Complete a comprehensive assessment of the 2.1. Use a general screening tool such as the Braden Scale,
individual. (Strength of Evidence = C) Norton Scale, Waterlow Scale, Braden Q (for pediatric
2. Assess the risk for new pressure ulcer development patients), or other age-appropriate tool in conjunction
on a regular basis by using a structured, consistent with clinical judgment. (Strength of Evidence = C)
approach which includes a validated risk assessment 2.2. Use the Marie Curie Centre Hunters Hill Risk
tool and a comprehensive skin assessment, refined by Assessment Tool, specific to individuals in palliative
using clinical judgment informed by knowledge of key care, in conjunction with clinical judgment for an adult
risk factors (see Risk Assessment section). (Strength individual. (Strength of Evidence = C)
of Evidence = C)
Pressure Redistribution
1. Reposition and turn the individual at periodic intervals, 1.7. Individualize the turning and repositioning schedule,
in accordance with the individual’s wishes and tolerance. ensuring that it is consistent with the individual’s goals
(Strength of Evidence = C) and wishes, current clinical status, and combination of
1.1. Establish a flexible repositioning schedule based co-morbid conditions, as medically feasible. (Strength
on individual preferences and tolerance and the of Evidence = C)
pressure-redistribution characteristics of the support 1.8. Document turning and repositioning, as well as the
surface. (Strength of Evidence = C) factors influencing these decisions (e.g., individual
1.2. Pre-medicate the individual 20 to 30 minutes prior to wishes or medical needs). (Strength of Evidence = C)
a scheduled position change for individuals who 2. Consider the following factors in repositioning:
experience significant pain on movement. (Strength of 2.1. Protect the sacrum, elbows, and greater trochanters,
Evidence = C) which are particularly vulnerable to pressure. (Strength
1.3. Observe the individual’s choices in turning, including of Evidence = C)
whether she/he has a “position of comfort,” after 2.2. Use positioning devices such as foam or pillows,
explaining the rationale for turning. (Strength of as necessary to prevent direct contact of bony
Evidence = C) prominences and to avoid having the individual lie
1.4. Comfort is of primary importance and may supersede directly on the pressure ulcer (unless this is the position
prevention and wound care for individuals who are of least discomfort, per individual preference). (Strength
actively dying or have conditions causing them to have of Evidence = C)
a single position of comfort. (Strength of Evidence = C) 2.3. Use heel protectors and/or suspend the length of the
1.5. Consider changing the support surface to improve leg over a pillow or folded blanket to float the heels.
pressure redistribution and comfort. (Strength of (Strength of Evidence = C)
Evidence = C) 2.4. Use a chair cushion that redistributes pressure on the
1.6. Strive to reposition an individual receiving palliative care bony prominences and increases comfort for an
at least every 4 hours on a pressure-redistributing individual who is seated. (Strength of Evidence = C)
mattress such as viscoelastic foam, or every 2 hours
on a regular mattress. (Strength of Evidence = B)
Source:
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment
of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009.
40 Healthy Skin
Nutrition and Hydration

1. Strive to maintain adequate nutrition and hydration 3. Offer several small meals per day. (Strength of
compatible with the individual’s condition and wishes. Evidence = C)
Adequate nutritional support is often not attainable 4. Offer nutritional protein supplements when ulcer healing
when the individual is unable or refuses to eat, based is the goal. (Strength of Evidence = C)
on certain disease states. (Strength of Evidence = C)
2. Allow the individual to ingest fluids and foods of choice.
(Strength of Evidence = C)
Skin Care
1. Maintain skin integrity to the extent possible. (Strength 1.2. Minimize the potential adverse effects of incontinence
of Evidence = C) on skin. See Prevention section.
1.1. Apply skin emollients per manufacturer’s directions to
maintain adequate skin moisture and prevent dryness.
(Strength of Evidence = C)

Pressure Ulcer Care

Pain management, odor control, and exudate control are the 3.3.2. Use dressings than can remain in place for longer
aspects of pressure ulcer care that tend to be most closely periods of time to promote comfort related to the
related to supporting the individual’s comfort. pressure ulcer care. (Strength of Evidence = C)
1. Set treatment goals consistent with the values and 3.3.3. Use a dressing that meets the needs of the individual
goals of the individual, while considering family input. for overall comfort and pressure ulcer care. See
(Strength of Evidence = C) section on Dressings. (Strength of Evidence = C)
1.1. Set a goal to enhance quality of life, even if the pressure 3.3.3.1. Consider use of an antimicrobial dressing to control
ulcer cannot be healed or treatment does not lead to bioburden and odor. (Strength of Evidence = C)
closure/healing. (Strength of Evidence = C) 3.3.3.2. Consider use of a hydrogel to soothe painful ulcers.
1.2. Assess the impact of the pressure ulcer on quality of life (Strength of Evidence = C)
or the individual and his/her family. (Strength of 3.3.3.3. Consider use of foam and alginate dressings to
Evidence = C) control heavy exudate and lengthen wear time.
1.3. Assess the individual initially and with any significant (Strength of Evidence = B)
change in condition, to re-evaluate the plan of care. 3.3.3.4. Consider use of polymeric membrane foam for
(Strength of Evidence = C) exudate control and cleansing. (Strength of
2. Assess the pressure ulcer initially and with each Evidence = C)
dressing change, but at least weekly (unless the 3.3.3.5. Consider use of silicone dressings to reduce pain
individual is actively dying), and document findings. with dressing removal. (Strength of Evidence = B)
(Strength of Evidence = C) 3.3.4. Protect the periwound skin with a skin protectant/
2.1. See Assessment and Monitoring Healing section for barrier or dressing. (Strength of Evidence = C)
general assessment information. 4. Control wound odor. (Strength of Evidence = C)
2.2. Monitor the ulcer in order to continue to meet the goals 4.1. Cleanse the ulcer and periwound tissue, using care to
of comfort and reduction in wound pain, addressing remove devitalized tissue. (Strength of Evidence = C)
wound symptoms such as odor and exudate. (Strength 4.2. Assess the ulcer for signs of wound infection:
of Evidence = C) increasing pain; friable, edematous, pale, dusky
3. Manage the pressure ulcer and periwound area on a granulation tissue; foul odor and wound breakdown;
regular basis as consistent with the individual’s wishes. pocketing at base; or delayed healing. (Strength of
(Strength of Evidence = C) Evidence = B)
3.1. Cleanse the wound with each dressing change using 4.3. Use antimicrobial agents as appropriate to control
potable water (i.e., water suitable for drinking), normal known infection and suspected critical colonization.
saline, or a noncytotoxic cleanser to minimize trauma to See Infection section. (Strength of Evidence = C)
the wound and help control odor. (Strength of 4.3.1. Consider use of properly diluted antiseptic solutions for
Evidence = C) limited periods of time to control odor. (Strength of
3.2. Debride the ulcer of devitalized tissue to control Evidence = C)
infection and odor. (Strength of Evidence = C) 4.3.2. Consider use of topical metronidazole to effectively
3.2.1. Debride devitalized tissue within the wound bed or control pressure ulcer odor associated with anaerobic
at edges of pressure ulcers when appropriate to the bacteria and protozoal infections. (Strength of
individual’s condition and consistent with the overall Evidence = C)
goals of care. (Strength of Evidence = C) 4.3.3. Consider use of dressings impregnated with
3.2.2. Avoid sharp debridement with fragile tissue that antimicrobial agents (e.g., silver, cadexomer iodine,
bleeds easily. (Strength of Evidence = C) medical-grade honey) to help control bacterial burden
3.3. Choose a dressing that can absorb the amount of and odor. (Strength of Evidence = C)
exudate present, control odor, keep periwound skin 4.4. Consider use of charcoal or activated charcoal dressings
dry, and prevent desiccation of the ulcer. (Strength of to help control odor. (Strength of Evidence = C)
Evidence = C) 4.5. Consider use of external odor absorbers for the room,
3.3.1. Use a dressing that maintains a moist wound-healing (e.g., activated charcoal, kitty litter, vinegar, vanilla,
environment and is comfortable for the individual. coffee beans, burning candle, and potpourri). (Strength
(Strength of Evidence = C) of Evidence = C)
42 Healthy Skin
Pain Assessment and Management

1. Perform a routine pressure ulcer pain assessment every 6. Select extended-wear-time dressings to reduce pain
shift, with dressing changes, and periodically as consistent associated with frequent dressing changes. (Strength of
with the individual’s condition (see Pain Management Evidence = C)
section). (Strength of Evidence = B) 7. Encourage individuals to request a time out during a
2. Assess pressure ulcer procedural and non-procedural pain procedure that causes pain. (Strength of Evidence = C)
initially, weekly, and with each dressing change. (Strength 8. For an individual with pressure ulcer pain, music,
of Evidence = C) relaxation, position changes, meditation, guided imagery,
3. Provide systematic treatment for pressure ulcer pain (see and transcutaneous electrical nerve stimulation (TENS)
Pain Management section). (Strength of Evidence = C) are sometimes beneficial. (Strength of Evidence = C)
4. If consistent with treatment plan, provide opioids and/or
non-steroidal antiinflammatory drugs 30 minutes prior to
dressing changes or procedures, and afterward. (Strength
of Evidence = C)
5. Provide local topical treatment for ulcer pain:
• Ibuprofen-impregnated dressings may help decrease
pressure ulcer pain in adults; however, these are not
available in all countries.
• Lidocaine preparations help decrease pressure
ulcer pain.
• Diamorphine hydrogel is an effective analgesic treatment
for open pressure ulcers in the palliative care setting.
(Strength of Evidence = B)
Resource Assessment
1. Assess psychosocial resources initially and at routine 3. Validate that family care providers understand the goals
periods thereafter (psychosocial consultation, social and plan of care. (Strength of Evidence = C)
work, etc.). (Strength of Evidence = C)
2. Assess environmental resources (e.g., ventilation,
electronic air filters, etc.) initially and at routine periods
thereafter. (Strength of Evidence = C)

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Survey Readiness
Urinary Incontinence Assessment

A Very Good Place to Start
It may be no surprise – especially to healthcare professionals who
work with the elderly – that more than 65 percent of nursing home
residents experience some type of urinary incontinence. In fact, it’s
the second most common reason – just behind dementia – that
individuals enter long-term care.1

BioCon™- 500
Bladder Scanner
Safely Measures
Bladder Volume
Minimize unnecessary catheterization
Research has shown that 80 percent of urinary tract
infections acquired at healthcare facilities are associated
with an indwelling urethral catheter.1 This type of infection
is known as CAUTI, or catheter-associated urinary
tract infection.
Avoiding unnecessary catheter use is a primary strategy

for preventing CAUTI, and clinical guidelines recommend
the consideration of alternatives to catheterization.2
Bladder scanners can be used in place of a urinary
catheter to assess bladder volumes, and many
catheterizations can be avoided.3
To learn more about

CAUTI prevention, visit
www.medline.com/erase
or contact your Medline
sales representative.
1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K,

Anderson DJ, et al. SHEA/IDSA practice recommendation:
strategies to prevent catheter-associated urinary tract infections
in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.
2. Stokowski, LA. Preventing catheter-associated urinary tract infections.
Medscape Nursing Perspectives. February 3, 2009.
3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations.
Med/Surg Nursing. 2005; 14(4):249-253.

Despite its prevalence, however, knowledge on how best to Once the resident is assessed, a plan of care should be
assess and manage urinary incontinence has been lacking. In developed to optimize bladder function and to prevent the use
2005 in an attempt to change this, the Centers for Medicare & of an indwelling catheter or urinary tract infection. Each plan
Medicaid Services (CMS) issued a surveyor guidance for incon- must be specific to the resident and his or her type of
tinence and urinary catheters under F-Tag 315, which focuses incontinence and include the rationale for a specific treatment
heavily on incontinence assessment. plan or management system.1
F-Tag 315 expects long-term care facilities to have systems and History, physical and testing. In a study of 30 nursing
procedures in place to ensure continence assessments are homes, the Borun Center for Gerontological Research, a joint
timely and appropriate interventions are defined, implemented, venture between the David Geffen School of Medicine at the Uni-
monitored and revised as necessary within current standards versity of California – Los Angeles (UCLA) and the Los Angeles
of practice. F-Tag 315 places emphasis on treating urinary Jewish Home, found that staff obtained medical histories for most
incontinence from the time of admission. The resident is to be incontinent residents, but less than 14 percent of those residents
evaluated at admission and whenever a change in cognition, received comprehensive physical exams. Rarer still were
physical ability or urinary tract function occurs. The intent of the recommended dipstick urinalyses, post-void residual measure-
guidance document is to ensure that:1 ments and 24-hour voiding records.2
• Incontinent residents are identified, assessed and provided
appropriate treatment to maintain as much normal urinary Post-void residual (PVR) testing determines the amount of
function as possible residual urine left in the bladder after a voluntary void. PVR
• Indwelling catheters are not used without medical justifica- measurement helps identify individuals in need of further medical
tion; if not justified they should be removed evaluation.4 Elevated PVR levels, signified at greater than 150
• Residents receive appropriate care to prevent urinary to 200 ml, can increase the risk of urinary retention and urinary
tract infections tract infection.1
Benefits of a Comprehensive There are two methods for measuring PVR: urinary catheterization
Continence Assessment2 and bladder ultrasound. There are many disadvantages of using
• Residents with reversible causes of urinary catheterization, including patient discomfort, risk of urethral
incontinence will get proper treatment, which in trauma, emotional distress and urinary tract infection. Catheteri-
turn will help them maintain their independence. zation also can be time-consuming.4 These downsides of direct
• Staff will be able to better target time-consuming urinary catheterization, are compelling in the frail elderly and are
toileting assistance to residents who truly need it. related to the low rate of PVR measurement.3
• The facility may score better on publicly reported quality
measures that reflect the quality of incontinence care. The safer alternative is the use of noninvasive portable
ultrasound measurement of PVR. The device is easy to use, it’s
Components of a urinary incontinence assessment non-invasive, time-efficient, minimizes medical waste and supplies
Assessment of incontinence is the key focus of the CMS and determines when catheterization is medically appropriate.
guidance and emphasizes identification of the cause. Assessment Portable 3-D ultrasound devices also have been shown to pro-
should include a history with documentation of previous treat- vide highly accurate measurements of bladder volume.4
ment, a physical exam and clinical testing. The clinician
assessing the resident also should consider the side effects of Uses for Portable Bladder Ultrasound5
medication as reasons for incontinence and other bladder-related • Measuring post-void residual urine volume
conditions, such as urinary retention.1,3 Although not specifically • Verifying an empty bladder or urinary retention
mentioned, the assessment is often best accomplished with the • Identifying an obstruction in an indwelling urinary catheter
help of nursing staff (particularly CNAs) who can provide more • Evaluating bladder distension and determining if
detailed resident information.3 catheterization is needed

HealthySkin16.3-mag:Layout 1 5/4/10 11:59 AM Page 48
Indicators of a
Quality Urinary
Incontinence
Assessment2
The following are quality indicators for a basic resident Medication side effects.6 In addition to other factors, side
assessment of urinary incontinence. These indicators were effects from some medications can contribute to incomplete
developed as a collaboration among the Borun Center, bladder emptying, primarily certain anticholinergics, tricyclic
other UCLA colleagues and researchers at RAND, a antidepressants, antipychotics, anti-Parkinson’s drugs, narcotics
southern California think tank. and anesthetic agents. The clinician evaluating the resident
should review all medications and consult with the physician(s)
regarding possible alternatives that would not contribute to
incomplete bladder emptying.
1 IF a nursing home resident has urinary incontinence
on admission or the new onset of urinary incontinence
that persists for over one month, Benefits of a urinary incontinence program4
In addition to increased dryness, benefits of implementing a
THEN a targeted history should be obtained urinary incontinence program at your facility include promotion of
that documents each of the following: mobility, range of motion, weight bearing, balance, skin integrity,
• Mental status bowel function, social interaction and emotional well-being.
• Characteristics of voiding
• Ability to get to the toilet Also, urinary incontinence researchers Johnson and Ouslander
• Prior treatment for urinary incontinence recommend that nursing homes market and promote their
• Importance of the problem to the resident urinary in continence services as a way to showcase their care
and clinical achievements. They believe this kind of promotion
could be quite successful knowing that many families struggle
2 IF a nursing home resident has new urinary with urinary incontinence care before deciding on nursing home
incontinence that persists for over one month or placement, and after admission, they express a high degree of
urinary incontinence on initial assessment, concern about urinary incontinence care vocalizing their distress
to the facility if this care is unsatisfactory.3
THEN the following tests should be obtained or
there should be documentation explaining why the
In one nursing home where the Duke School of Nursing
test was not completed:
implemented a comprehensive urinary incontinence program
• Dipstick urinalysis
collaboratively with staff, the director of nursing reported that
• Post-void residual volume
family complaints on Monday mornings went from 20 to virtually
• 24-hour voiding record
none after implementing prompted voiding.
The director of nursing said having nurse aides administer the

References
1. Newman DK. Urinary incontinence, catheters and urinary tract infections: an prompted voiding program on 12-hour shifts seven days a week
overview of CMS Tag F 315. Ostomy Wound Management. 2006; 52(12):34-36.
ensured continuity of care and good outcomes. In addition, the
2. Incontinence Management. Borun Center website. Available at:
http://www.geronet.med.ucla.edu/centers/borun/modules/Incontinence_manage- aides took pride in their role, calling themselves the “Quality Care
ment. Accessed April 21, 2010.
3. Lekan-Rutledge D. The new F-Tag 315. Journal of the American Medical Directors
CNAs,” reflecting their ownership of the program.
Association. 2006; 7(9):607-610.
4. Kelly C. Evaluation of voiding dysfunction and measurement of bladder volume.
Reviews in Urology. 2004; 6(Suppl 1):S32-S37. Focusing on evidence-based clinical services such as urinary
5. Patraca K. Measure bladder volume without catheterization. Nursing. 2005;35(4): incontinence care certainly has the potential to distinguish high-
46-47.
6. Newman DK. Using the BladderScan for bladder volume assessment. quality facilities and attract new admissions in competitive
Seek Wellness website. Available at: http://www.seekwellness.com/incontinence/ markets while gaining community recognition.3
using_the_bladderscan.htm. Accessed April 21, 2010.
48 Healthy Skin
It’s another level of

comfort
and
protection
Restore® briefs provide maximum

dryness with skin nourishment built right in.
Restore briefs not only keep wetness away from your residents’ skin, they
also help provide protection from skin irritation with a coating of Medline’s Remedy®
Skin Repair Cream on the inner liner. Using a combination of the Remedy skincare line
and the Restore brief was shown to keep the pressure ulcer incidence rate
and incontinence-associated dermatitis prevalence rate down according to a retrospective,
cohort study conducted at Meridian Nursing and Rehabilitation in Brick, NJ.1
The brief’s absorbent UltraCare core helps provide maximum dryness for improved
comfort and protection. And the cloth-like outer cover is comfortable against the skin,
helping to minimize rash or irritation.
Purchase a 12-month supply of Restore briefs and

receive one month free. For details contact your Medline
representative or call 1-800-MEDLINE.
1 Shannon R., Fisher K. A Nursing and Rehabilitation Center Project in New Jersey: Expected Value of Remedy Skin Care and Restore
Briefs in an At-Risk Resident Population for Pressure Ulcer and Incontinence-Associated Dermatitis Prevention. ©2010 Medline Industries, Inc. Medline
is a registered trademark of Medline Industries, Inc.
Special Feature
10 Tipsfor Bathing the Uncooperative Resident

By Lorri A. Downs, BSN, MS, RN, CIC
Most caregivers have experience with bathing residents; however, 6. Develop policies and procedures that allow caregivers to
the uncooperative resident can present safety challenges to defer bath time in cases when the resident is feeling
themselves and employees. uncomfortable. Educate the resident’s family and explain
this plan of care. Forced bathing does not work and only
Here are 10 tips to make the bath experience easier and
increases the resident’s anxiety.
more enjoyable.
7. Create a home-like atmosphere in the bathing area. A familiar
1. Eliminate anything that could make the bath experience environment creates a pleasant experience and encourages
uncomfortable. Provide the bath in a private area, keeping participation.
the resident warm and covered. This can help reduce 8. Save time by individualizing the bathing experience. When
embarrassment and increase cooperation. the resident participates and the experience is person-
2. Move slowly and communicate clearly to express centered, it actually facilitates the bathing process to
reassurance. move more quickly and efficiently with little or no conflict.
3. Consistently assign the same caregiver to the same resident 9. Adjust bathing terminology accordingly. Using the word
to help develop trusting relationships. “bath” invokes a negative feeling in some residents.
4. Take time to ask about the individual’s bathing preferences Instead invite the resident to “wash up,” which may
to personalize the experience, decrease anxiety and sound less threatening.
increase participation. 10. Perform hair washing separately. Create a “beauty shop”
5. Remain flexible, using different bathing techniques to meet experience, which is less threatening because the resident
individual needs and preferences. is fully clothed.
50 Healthy Skin
Regular Feature
Hotline Hot Topic
By Elizabeth O'Connell-Gifford, BSN, MBA,

RN, ET/CWOCN, DAPWCA
Question:
We are looking for some ideas for an independent 80-year- The patient is essentially bedbound when no one is there
old female patient who would qualify for skilled care, but to help her. The aide cleanses the patient with antibacter-
refuses to leave her home. She fell 18 months ago and ial soap and helps her to the toilet. Before leaving, the aide
fractured her femur. She had an ORIF done, completed applies a thick coating of petrolatum-based ointment
rehab, and then returned home with limited mobility. She and a disposable brief.
is a Medicaid patient, so she only qualifies for certain
disposable incontinence and skin products and limited Answer:
nurse’s aide visits. Her 60-year-old daughter helps on the First, identify the issues as skin-related secondary to
weekends. incontinence and mobility, products inappropriate for the
patient, budget restraints, patient dignity concerns and
The patient has two open areas on her buttocks measur- education deficits.
ing 4 cm x 3 cm x 0.4 cm. The aide reports that the patient
is usually lying in a very saturated brief. Her hydrocolloid Incontinence is defined by the Centers for Medicare &
dressing usually has fallen off due to the excessive moisture. Medicaid Services (CMS) as the involuntary loss or leak-

Newer incontinence management products offer a more

cost-effective and efficient alternative.
age of urine. 1 Years ago we may have dealt with the Using a combination of the Remedy skincare products and
incontinence by placing a foley catheter. Today, the evi- the Restore brief was shown to keep the pressure ulcer
dence-based data reveals that catheters put patients at incidence rate and incontinence-associated dermatitis
risk for developing a catheter-associated urinary tract prevalence rate down in a retrospective, cohort study con-
infection (CAUTI). ducted at Meridian Nursing and Rehabilitation in Brick, NJ.3
It sounds like the patient has functional incontinence. Another important factor would be making sure the brief is
Obtaining an evaluation for improving mobility and access sized correctly to prevent leakage and skin damage. There
to a commode when she is by herself would be a good is a myth that larger briefs absorb more urine or are easier
idea. A thorough assessment of the incontinence prob- to apply. Oversized briefs require more frequent changing
lem should be conducted as well. and allow urine to flow out onto the sheets and underpads.
Appropriate sizing and a brief that does the job will pro-
The low-cost brief the patient has been wearing, which mote patient dignity, self-esteem, healthier skin and will
consists of cotton fluff and a plastic exterior, can be a hos- prove cost-effective in the long run.
tile environment for the skin. The cotton fluff tends to lump
together and absorb very little, allowing urine, fecal Open-airing the buttock and perineal area at night with a
enzymes and bacteria to assault the skin. The plastic super-absorbent disposable underpad, such as Ultra-
backing is not breathable and contributes to the moisture sorbs® AP, wicks moisture away from the patient. A stan-
load, which leads to skin breakdown. The petroleum- dard size pad can absorb a liter of fluid, and the top lining
based product being used is greasy, can be occlusive dries in seven minutes. I also recommend the zinc-based
to the skin and can clog the facing/lining of the brief, barrier cream, Calazime®, which acts as a “dressing in
decreasing absorbency. Newer incontinence management a tube.”
products offer a more cost-effective and efficient alternative.2
Although Medicaid does not reimburse for higher end
A newer disposable product called the Restore brief not
® products, the continuing damage to the skin and the fact
only keeps wetness away from patients’ skin, it also that the wounds are not healing because they are swim-
helps provide protection from skin irritation with a coating ming in urine every night, increases the cost of wound care
of Remedy Skin Repair Cream on the inner liner. The brief’s and the frequency of nurse’s aide visits. The cost of care
absorbent core helps provide maximum dryness for should be evaluated as a whole with a focus on prevention.
improved comfort and protection.
52 Healthy Skin
PERIOPERATIVE PRESSURE
Are you facing a skin or wound care ULCER EDUCATION.
dilemma with a patient or resident?
MORE IMPORTANT
Call Medline’s Educare Hotline at 888-701-SKIN (7546) THAN EVER BEFORE
“
to discuss a wound care issue with one of our
experienced wound care nurses. The hotline is available
Monday through Friday, 8 am to 5 pm, Central Time. I have seen an increase in
the number of legal issues
linking facility-acquired pressure
ulcers to post-surgical patients.
A pressure ulcer program for the
References OR is more critical than ever.”
1. CMS Manual System: Revision of Appendix PP – Section 483.25(d) – Urinary
Incontinence, Tags F315 and F316 Tag. Available at: http://www.oashs.org/ Diane Krasner, PhD, RN, CWCN,
content/PDF/2005/incontinence_guidance.pdf. Accessed April 23, 2010. CWS, BCLNC, FAAN
2. Rothfeld AF & Stickley A. A program to limit urinary catheter use at an acute care
hospital. American Journal of Infection Control. 2010. In press.
3. Shannon R., Fisher K. A nursing and rehabilitation center project in New Jersey: Medline’s Pressure Ulcer Prevention Program
expected value of Remedy skin care and Restore briefs in an at-risk resident now has a component designed specifically for the
population for pressure ulcer and incontinence-associated dermatitis prevention.
Available at: http://www.medline.com/wound-skin-care/lit/Approved%20New%20 perioperative services. The easy-to-use interactive
Jersey%20Remedy-Restore%20Study.pdf. Accessed April 15, 2010. CD addresses the following:
• Hospital-acquired conditions
• CMS reimbursement changes
About the author
• Best practices for pressure ulcer prevention
Elizabeth O'Connell-Gifford, BSN, MBA, RN, ET/CWOCN,
• Perioperative assessment tools
DAPWCA is a board-certified wound, ostomy and continence nurse.
• Critical patient and equipment risk factors
Remedy is a registered trademark of Medline Industries, Inc.

Restore is a registered trademark of Medline Industries, Inc. To learn more about Medline’s
Ultrasorbs is a registered trademark of Medline Industries, Inc. Pressure Ulcer Prevention Programs
Calazime is a registered trademark of Medline Industries, Inc. for long-term care, acute care and
perioperative services, call your
Medline representative or visit
www.medline.com/pupp-webinar.

What did we do after

designing a revolutionary
new catheter tray system?
We found THREE more ways

to make it even better.
We’re obsessed with engineering new and better Combined with the previous innovative tray redesign
technology for healthcare workers. So after we and comprehensive ERASE CAUTI education, these
revolutionized the outdated Foley catheter tray with three new features help to improve patient safety and
a unique, one-layer system design, we immediately quality, while reducing avoidable costs associated with
turned our attention to addressing how we could waste and urinary tract infections.
make it even easier to use. We studied how the
tray was being used in the field. The result was To learn about the ERASE CAUTI system, as well as
three more great improvements. other strategies for minimizing the risk of CAUTI, sign
up for a free Innovation in the Prevention of CAUTI
webinar at www.medline.com/erase/webinar.
1 Real photography on the outside –

so you know exactly what’s inside
A photo on the package helps identify the
contents of the kit, serves as an educational
tool for the clinician and can be used to
discuss the procedure with the patient.
Also, the label opens up to a booklet with
step-by-step instructions and helpful tips
for the clinician.
2 A checklist that fits better

in the medical record
The reformatted checklist is smaller, making
it easier to fit in the patient chart or medical
record. It is also available as an attachment
for electronic documentation.
3 Education you’ll want to present

to your patient
There’s nothing like the new Patient
Education Care Card. Designed to look
and feel like a “Get Well Soon” card, it
tells patients about catheterization so
they know you are providing them the
best care possible.
6
Sticky
Wickets that
Commonly
Occur in
Wound Care
Lawsuits
56 Healthy Skin
Special Feature
By Diane L. Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN
With wound care litigation on the rise, it is prudent for In several recent legal cases I have personally reviewed,
healthcare professionals and facilities to engage in the failure occurred when the wound nurse was on vaca-
preventive legal care.1 One approach is to analyze com- tion. There were significant delays in treatment that
mon problems that occur in wound care lawsuits. Based impacted the plan of care and were difficult to defend
on a review of more than 40 legal cases, six sticky wickets in litigation.
and approaches for managing them are identified and
elaborated on here. 2. Scope of Practice
Wound care practitioners who practice outside of the
The Six Sticky Wickets scope of their practice – while often admired for their
1. 24/7 coverage, holidays and vacations commitment – open themselves up to serious problems
2. Scope of practice should a lawsuit be brought against them or their facility
3. Symptom management (vicarious liability).
4. SCALE2
5. Communication to the patient’s circle of care Scope of practice is determined by statutory law (state
and other healthcare professionals practice acts) and varies from state to state. The follow-
6. Documentation ing are examples of common scope of practice problems
in wound care that have the potential for wound care
1. 24/7 Coverage, Holidays and Vacations practitioners to lose their license to practice through the
The emerging standard of care is to provide wound care administrative court system:
expertise 24/7 for assessments, consults or other rec-
ommendations. It is less and less acceptable for a wound Example 1. A registered nurse debriding to bleeding tis-
patient who is admitted on a Friday, for example, to wait sue (wide excision) in a state where RN debridement is
until Monday morning for a wound consult. Facilities restricted to devitalized tissue. Check with your state
should have a protocol or some systematic method for board of nursing to seek clarification regarding specifics.
wound care services to be delivered in a timely manner.
Example 2. A non-physician or non-physician extender
Options include: ordering a prescription topical (e.g., an enzymatic debrider
• Standing orders or guidelines – even by protocol) or an FDA device (e.g. NPWT).
• Cross training staff to cover (e.g., hospitalists
in acute care; supervisors in long-term care) Example 3. In any setting, an LPN/LVN wound nurse
assessing wounds and carrying out wound care per
In addition, there should be a formalized plan to cover protocol, without ongoing assessments and oversight by
wound services when the “wound nurse” or “wound a licensed provider (nurse, physical therapist, physician
physician” is on vacation. or physician-extender). LPNs/LVNs monitor; licensed
providers assess.

3. Symptom Management In addition, there should be discussion with the patient

Holistic patient care requires that patient-centered con- and his or her circle of care regarding the non-healing
cerns, such as pain management or nutritional support, nature of the wound. This discussion should be docu-
be addressed by the interprofessional wound team. mented in the patient’s medical record.
Excellent local wound care in the absence of total patient
care can be problematic if a lawsuit is filed. Recently, large To download a copy of the SCALE Final Consensus
add-on awards have been won for lack of attention to Statement and related documents, go to www.gaymar.com
pain management in several wound cases (pain and suf- under Clinical Support & Education.
fering awards). Punitive damages have been awarded in
cases for lack of attention to nutritional support, consid- 5. Communication to the Patient’s Circle
ered “elder abuse.” of Care and Other Healthcare Professionals
When patients and members of their circle of care
Timely consultation with pain specialists, dietitians or (spouses, significant others, caregivers) are included in
other providers based on an individual’s assessed needs healthcare discussions and decision-making, they are
improves patient outcomes and decreases the risk of less likely to sue. “Lack of knowledge about pressure
legal problems. ulcers fuels unrealistic expectations about their treat-
ment and prognosis and could set the stage for
4. Skin Changes At Life’s End (SCALE) potential litigation.”1
Not all wounds are healable,
including those wounds associ- Facilities should have quality management or risk man-
ated with Skin Changes At Life’s agement teams who can train and assist wound care
End.1 Failure to acknowledge a clinicians in communicating with patients and their circle
non-healable wound in the plan of care and not record- of care. Each individual needs to know what level of
ing that wound in the patient’s medical record creates a communication they are responsible for.1
sticky wicket.
6. Documentation
For example, using a boilerplate care plan that states The number one sticky wicket in wound care lawsuits is
“wound will be healed in 90 days,” when the wound incomplete or missing documentation. The most impor-
is non-healable, makes the case almost impossible to tant strategy for preventive legal care is documentation.
defend in a lawsuit situation. Good documentation is comprehensive, consistent,
concise, chronological, continuing and also reasonably
complete.1
58 Healthy Skin
I have frequently observed the following documentation

problems during chart reviews, and they create sticky
wickets for wound care defense:
• Inconsistent documentation of wound size,

stage or location from one provider to another:
Example
The physician documents:
2 x 3 cm Stage II Sacral decub
On the same patient’s chart, the nurse writes:

5 x 6 x 2 Stage IV L hip pressure ulcer
• Incomplete documentation of information

requiring detail:
Example
What is a
Order reads: Specialty bed & chair cushion
(This order is too vague.)
sticky wicket anyhow?
The term sticky wicket comes from the British game
Order needs to list specific types of products:
cricket and refers to “a pitch that has become wet
e.g., low air loss mattress replacement &
because of rain and therefore on which the ball
air-filled chair cushion
bounces unpredictably.”3 In common parlance, sticky
wicket has come to refer to “a difficult or unpredictable
• As the risk assessment score changes for a
situation.”3
patient (e.g., Braden Scale score falls from
18 to 13), there is no documentation of a
change in the plan of care.
Conclusion
Good preventive legal care for wound care involves plan- About the author
ning and preparing so that unpredictable situations are Dr. Diane L. Krasner is a wound and skin
avoided. Addressing the “Six Sticky Wickets that Com- care consultant in York, Penn. She works
part-time at Rest-Haven York, is lead
monly Occur in Wound Care Lawsuits” can help protect
co-editor of Chronic Wound Care
you and your facility from litigation.
(www.chronicwoundcarebook.com) and
served as co-chair of the SCALE Panel
and corresponding author of the SCALE
References
1. Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, et al. Legal Final Consensus Statement. You may reach Dr. Krasner at
issues in the care of pressure ulcer patients: key concepts for healthcare dlkrasner@aol.com.
professionals: a consensus paper from the International Expert Wound Care
Advisory Panel. J Palliat Med. 2009;12(11):995-1008. Available at:
http://www.medline.com/media-room. Accessed April 13, 2010.
2. Sibbald RG, Krasner DL, Lutz JB, et al. Skin Changes at Life’s End:
Final Consensus Statement. October 1, 2009. Available at:
http://www.gaymar.com. Accessed April 13, 2010.
3. Wiktionary website. Available at www.wiktionary.com. Accessed
April 13, 2010.
© 2009 Diane L. Krasner

1 Contact Hour
LEGAL IMPLICATIONS OF PRESSURE ULCERS
Join us for this webcast presentation as two industry experts bring you critical informa-
tion on how the utilization of the nursing process and proper documentation are vital
components in maintaining the standard of care and avoiding litigation.
Dr. Caroline Fife is the Chief Medical Officer of Intellicure, Inc. and is
an Associate Professor within the Department of Medicine, Division
of Cardiology at the University of Texas Medical School at Houston
and Director of Clinical Research at the Memorial Hermann Center for
Wound Healing and Hyperbaric Medicine. She has served on the
Boards of the American Academy of Wound Management and
the Association for the Advancement of Wound Care. She is the
co-editor of the textbook, "Wound Care Practice" and is the author
of many scientific papers.
Kevin Yankowsky is a partner in the health law litigation group

of Fulbright & Jaworski L.L.P.’s Houston office. A true trial lawyer,
Kevin’s trial practice encompasses virtually all types of civil litigation
facing the healthcare industry. In addition to his extensive courtroom
experience, he advises on Joint Commission investigations, hospital
committee and medical peer review matters.
To view this webcast visit

www.medlineuniversity.com
Courses approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing.
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offloading.1,2 Offloading is achieved with the use of pillows or heel protection devices that
relieve pressure by elevating the heel.
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1
Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing
heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48.
2
Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers:
stand guard. Advances in Skin & Wound Care. 2008;21(6):282-292.
The CNO Perspective:
62 Healthy Skin
Prevention
By Connie Yuska, MS, RN, CORLN
One of the major responsibilities of the chief nursing officer Quality Health Care (NCQHC) to become an organization
(CNO) is to lead initiatives and remove barriers to enable of health industry leaders focused on promoting public
the bedside nurse to deliver high quality, safe patient care. awareness of solutions to problems confronting the
Since the Medicare payment implications for pressure ul- American healthcare system.
cers as a secondary diagnosis if acquired during a hos-
pitalization went into effect October 1, 2008, much Two reports issued by the Institute of Medicine focused
activity has centered on education programs and use of on quality issues in the healthcare system. The first, To
appropriate products; all with the goal of reducing hospi- Err is Human: Building a Safer Health System, highlighted
tal-acquired pressure ulcers. The focus of work regarding the number of preventable medical events that occur in
education and reporting of outcomes has been taking the United States each year. Pressure ulcers were among
place at all levels, from the staff level to physicians to the the most common preventable events listed. The second
hospital board. report, Crossing the Quality Chasm: A New Health System
for the 21st Century addressed restructuring the entire
CNOs develop targeted communication to a variety of healthcare system to make better use of available
stakeholders in the institution; however, the boards of resources and to provide better patient care. This report
directors at hospitals across the country are an especially focused on patients with chronic conditions. A recom-
interested audience. Over the past decade, there has mendation in the To Err is Human report, which en-
been an increasing focus on the quality of care provided couraged large companies to use employer purchasing
in hospitals and a corresponding shift in attention to qual- power to promote advances in healthcare quality and
ity and safety at the board level. safety, prompted the formation of The Leapfrog Group in
late 2000. The Leapfrog Hospital Rewards Program
U.S. healthcare quality initiatives measures hospital performance in key areas and provides
The drive for transparency in outcomes, coupled with information to member employers and consumers to
targeted attention on quality and safety has fueled this assist them in making an informed choice when choosing
response. The 1990s saw rising healthcare costs, along a healthcare provider.
with increasing demands from employers and third-party
payers to improve efficiency, lower costs and improve Getting the board up to speed
quality.1 Another significant event that occurred to drive The growing demand for improved quality and safety
the quality movement was the creation of the National in the American healthcare system from consumers, gov-
Quality Forum (NQF) in 1999. The goal of the organiza- ernment agencies, insurers and accrediting bodies places
tion was to develop and implement a national strategy for an increased responsibility on the board of directors to
healthcare quality measurement and reporting.1 Today, ensure the hospital achieves quality outcomes. Board
the NQF has merged with the National Committee for members are trying to understand what is happening at

Pressure
Ulcer
Prevention
the bedside. Their responsibilities include ensuring quality The board also will be very interested in the financial
systems are in place and making decisions regard- reality of non-payment from the Centers for Medicare &
ing the allocation of resources. It is the CNO’s Medicaid Services (CMS) for hospital-acquired pressure
re sponsibility to present the data and describe the ulcers and the potential impact that will have on the
environment that is needed to ensure that the board hospital’s financial results. As such, a brief overview of
understands the issue and will approve programs and the systems to support documentation and coding would
products nurses at the bedside need to reduce the be appropriate.
incidence of pressure ulcers.
The metrics related to pressure ulcer incidence should
Often, hospital board members lack medical background. also be included on a quality scorecard and be compared
Many come from a manufacturing environment where the to national benchmarks for pressure ulcer incidence. For
goal is “zero defects.” Therefore, they may find it difficult many, benchmarks to lower pressure ulcer incidence will
to understand how a patient can enter a hospital for care be built into the nursing strategic plan under the quality
and acquire a pressure ulcer. of care section. This will ensure that the metric will be
followed by the board on an ongoing basis.
Board discussions should include an outline of a compre-
hensive plan to educate all nursing staff on the importance The goal should be to encourage the board to establish
of skin assessment and care, protocols that include pressure ulcer reduction as a strategic priority. The target
assessing the patient using a validated scale, identifica- of reducing pressure ulcers should be communicated to
tion of high-risk patients and plans to put the patient on a board members, administration, medical directors, physi-
care pathway that will prevent development of a pressure cians, other providers, staff and patients and their families.
ulcer. The CNO also should lead a conversation about the Outcome data also should be communicated regularly to
internal systems in place to prevent pressure ulcers. These all of the aforementioned groups so progress can be
systems will include identifying the roles of healthcare tracked and necessary plan modifications can be made.
team members, including the physician, nurse, patient
care technician, physical therapist, dietitian and social Building a culture that values transparency and supports
worker. In addition, the CNO will find it helpful to present education and the use of appropriate products from the
an overview of a selection process for evidence-based board level to administration to the staff will be effective in
products shown to be effective in protecting the skin to achieving the goal of reducing facility-acquired pressure
decrease the possibility of developing a pressure ulcer. ulcers and improving the quality of care provided
This demonstrates the value of choosing evidence-based to patients.
products shown to be effective through research. Finally,
Reference
a methodology for capturing and reporting data related to
1. Getting the Board on Board: What Your Board Needs to Know About Quality
the incidence of pressure ulcers, as well as measurements and Patient Safety. Oakbrook Terrace, Ill.: Joint Commission on Accreditation
for the amount of learning that occurred from the educa- of Healthcare Organizations, 2007.
tion program, should be presented.
64 Healthy Skin
JOIN THE PROGRAM TO

REDUCE PRESSURE ULCERS
“
We’ve made pressure ulcer prevention easy.
Systematic efforts at education, heightened awareness This has been a great learning experience for
and specific interventions by interdisciplinary healthcare our staff and for our facility as a whole. I am
teams have demonstrated that a high incidence of thankful Medline had this program and that we
pressure ulcers can be reduced.1 The main challenges were able to access it. I can’t imagine recreating
to having an effective pressure ulcer prevention program this wheel!”
are: lack of resources; lack of staff education; behavioral Katrina “Kitty” Strowbridge, RN
challenges; and lack of patient and family education.2 Quality Improvement Coordinator
St. Luke Community Healthcare Network
Medline’s comprehensive Pressure Ulcer Prevention
Ronan, Montana
Program offers solutions to these challenges.
The Pressure Ulcer Prevention Program from Medline

For more information on the Pressure Ulcer
will help you in your efforts to reduce pressure ulcers in
Prevention Program, contact your Medline
your facility. The program includes:
representative, call 1-800-MEDLINE or visit
• Education for RNs, LPNs, CNAs and MDs www.medline.com/pupp-webinar to register
• Teaching materials for you to help train your staff for a free informational webinar.
• Practical tools to help reduce the incidence of
pressure ulcers
• Innovative products supported by evidence-based
information that result in better patient care
References
1
Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.
2
CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.
Announcing New Online Skin &

Risk Assessment Competency
The Latest Addition to Medline’s
Pressure Ulcer Prevention Program
Medline’s Pressure Ulcer Prevention Program –
an educational initiative aimed at reducing the inci-
dence of pressure ulcers – has added an interactive
online competency to allow nurses to demonstrate
what they’ve learned in a virtual clinical setting.
This approach provides consistency, as each
learner performs the same assessments.
The learner proceeds through the compe-

tency using the computer mouse to com-
plete each step – from dispensing hand
sanitizer at the wall unit to pulling back the
bed linens and patient gown, performing
assessments on three separate patients.
An illustrated hand replaces the usual
mouse arrow on the screen.
James is a 44-year-old male who

is recovering from a heart attack.
66 Healthy Skin
Prevention
Sarah is in a coma with a naso-gastric

feeding tube. She has a visible wound
on her right arm.
When the learner clicks on Sarah’s

arm, a close-up photograph of her
wound and a related multiple choice
question appear on the screen.
At the end of each skin assessment, the

learner completes the Braden Scale to
determine the patient’s level of risk for
pressure ulcers.
The only way to access the Skin and Risk

Assessment Competency is by joining the
Pressure Ulcer Prevention Program. Visit
www.medline.com/PUPP-webinar to sign up
for an informational webinar to learn more.
(See back cover for webinar dates.)

68 Healthy Skin
Treatment
NUTRITIONAL
SUPPLEMENTS
WHAT APPROACH IS BEST FOR YOUR RESIDENT?
It can be challenging to properly nourish individuals who chewing is compromised or an obstruction prevents food
have functional gastrointestinal tracts but are otherwise from passing through the digestive system. Deciding
incapable of consuming conventional food orally or in large whether to use parenteral or enteral feeding is very much
enough quantities to be nutritionally effective. patient-specific and should be made after consultation with
appropriate members of the treatment team. Information
Three options are available for delivering the metabolic sup- facilitating the decision may be gleaned from the numerous
port necessary to prevent starvation and the loss of lean clinical studies directed to the use of enteral feeding in
tissue that accompanies starvation. These include total par- patients treated for trauma, burns, surgery, inflammatory
enteral feeding (TPN), which is administered through an IV, bowel disease, pancreatitis, and protein-energy under
enteral feeding, which is delivered directly to the stomach nutrition. The following are highlights from several of
through a feeding tube, and oral supplementation with these studies.
liquid concentrates.
Trauma. According to a study published by Moore and
Both parenteral and enteral feeding can adequately meet Jones in 1986, moderately injured trauma patients had a
the nutritional needs of patients; however, of the two significantly reduced incidence of pneumonia and intra-
options, enteral feeding has proven to be the more abdominal abscesses when fed enterally.1 The study con-
economical approach that also is associated with fewer sisted of two groups of patients – one group was fed a
infections and faster recovery time for the patient. chemically defined diet administered enterally via a jejunos-
tomy, and the second group was fed parenterally with
Applications of Enteral Feeding fluids containing only dextrose. Neither group included pa-
Nutritional support is imperative when the patient’s tients with severe intra-abdominal injuries or severe pelvic
gastrointestinal tract functions, but either swallowing or fractures. The enterally fed group had significantly fewer

intra-abdominal abscesses. After critics attributed the As a result of these and other clinical studies, many trauma
higher rate of infections in the IV group to malnutrition in- centers consider enteral feeding the preferred option in
duced by the parenteral diet, the study was repeated in the patients whose gastrointestinal tract remains functional and
IV group patients.2 This time, the group was fed in two can be accessed at a suitable site.4
phases: in the first phase, they were randomly assigned to
receive enteral or parenteral feeding; and in the second Burns. Enteral feeding is generally the preferred nutritional
phase, all patients were fed parenterally. The repeated study support in patients suffering from severe burns and should
confirmed the significant reduction in the incidence of be started as early as possible to help reduce the develop-
pneumonia and intra-abdominal abscesses in the enteral- ment of gastroparesis – a condition of “delayed gastric
fed group. emptying,” in which the stomach takes too long to empty
its contents.4
Similar results were noted by Kudsk et al. in a study pub-
lished in 1992 for a subgroup of patients who had severe Surgery. Perioperative nutrition – that is, nutrition provided
injuries and a 25 percent or greater chance of developing through the night before surgery, during surgery, and
sepsis.3 The injuries of this subgroup affected the intra- immediately afterward – not only provides surgical patients
abdomen and multiple systems such as the chest, head, with the requisite nutrition, but also enhances their immune
skeleton and/or abdomen. The study showed that the risk systems, helping reduce complications.5 According to a
of infection was low in patients with mild injuries, irrespec- host of studies, determining which mode of feeding – par-
tive of whether they were fed enterally or parenterally. How- enteral or enteral – is better appears to be influenced by the
ever, in patients with severe injuries, the incidence of septic patient’s nutritional status and the severity of the injury or
complications – namely pneumonia followed by intra- illness. Kondrup et al. found that people with less severe
abdominal abscesses – increased six to 11 times in illnesses and a low degree of existing malnutrition gained
patients fed parentally. little benefit from nutritional intervention.6 By contrast, indi-
70 Healthy Skin
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e co n
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antiox
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lutein
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21 grams of protein per serving
Active Liquid Protein Liquid Protein mixes easily into
ENT697 Citrus Berry Punch, Critical Care,
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Nutrition Facts
soups and beverages. One serving
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Servings per Container: approx. 32
Amount per serving

to nearly four servings of protein
Calories 90 powder), plus arginine, leucine,
% Daily Value* glutamine and zinc to provide
Total Fat 0g
Saturated Fat 0g
0%
0%
support during wound healing
Trans Fat 0g 0% and for the immune system. One
Cholesterol 0mg 0% serving also provides 6mg of lutein,
Sodium 20mg 1%
Potassium 30mg 0%
an antioxidant which promotes eye
Total Carbohydrate 0g 0% health and healthy skin.
Dietary Fiber 0g 0%
Sugars 0g
Protein 21g 42% Available in two tasty flavors: Citrus
Vitamin A 0% Vitamin C 363% Berry Punch and Orange Créme.
Calcium 0% Iron 0%
Phosphorus 6% Zinc 60%
*Percent Daily Values are based on a 2,000 calorie diet
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NUTRITIONAL
SUPPLEMENTS
viduals suffering from a greater occurs fairly quickly. In many

degree of malnutrition or more severe cases, however, patients
severe illnesses – such as are unable to consume a normal
individuals about to undergo diet for several days after an acute
high-stress surgical procedures occurrence of the disease. For
such as pancreatectomy or this group, enteral feeding
esophagectomy – benefited the appears promising, as it offers
most and had fewer infections effective nutrition support.
and non-infectious complica-
tions when fed enterally. Enteral feeding has been shown
to reduce the incidence of infec-
Inflammatory bowel disease/ tions, the length of the patient’s
Crohn’s disease. In individuals hospital stay and the patient’s
experiencing severe attacks of hospital costs. In 2004 Alsolaiman
ulcerative colitis, enteral nutri- et al. reported on these benefits
tion has been shown to be a safe from a study of 53 patients admit-
and effective way to deliver ted for acute pancreatitis.9 The
nutrients. In a 1993 study by patients were randomized to
González-Huix et al. concerning receive parenteral feeding or en-
42 patients with severe acute teral feeding via a nasojejunal
ulcerative colitis, enteral nutrition tube. Relative to the parenteral
was compared with total par- group, the enterally fed patients
enteral nutrition as an adjunct were on nutrition support for a
therapy to steroids.7 Patients were randomly assigned to significantly shorter time – 6.7 days versus 10 days for
receive polymeric total enteral nutrition or isocaloric, isoni- parentally fed patients. The enterally fed group also had a
trogeneous total parenteral nutrition as the sole nutritional shorter hospital stay – that is, an average stay of 14 days
support. Compared with the parenterally fed patients, versus 18 days. In addition, 80 percent of the enterally fed
patients receiving enteral nutrition had more than a 3.6-fold group transitioned to a normal diet without difficulty, com-
increase in serum albumin and almost 75 percent fewer pared to 63 percent for the parenteral group.
adverse effects, including fewer post-operative infections.
Protein-energy undernutrition. Managing the care
For patients with active Crohn’s disease, several studies and of elderly, undernourished and frail patients remains a
meta-analyses suggest that enteral nutrition is an effective challenge. The determination that a patient suffers from
therapy, though less effective than steroids. Although protein-energy undernutrition (PEU) is typically made after
enteral nutrition is rarely used as the sole therapy for adults, measurement of serum albumin, prealbumin and choles-
it is regarded as the treatment of choice for children.8 terol, together with body mass index, weight loss, mid-arm
circumference and suprailiac skinfold measurements.10
Pancreatitis. In the inflammatory disease known as pan-
creatitis, the pancreatic enzymes autodigest the gland. A Enteral feeding is one means of providing adequate dietary
typical therapeutic regimen includes fluid replacement, protein to PEU patients, especially through oral supple-
bowel rest, parenteral nutrition and antibiotics. For patients mentation with concentrated proteins. Protein-supple-
treated with this conventional therapy, resolution generally mented enteral diets improve the nutritional status of the

patients; however, other treatment modalities

such as muscle strengthening may be required to
improve long-term outcomes.
Reducing the Incidence of Infections

Numerous studies conducted with trauma and surgical
patients show that the delivery of nutrients directly to the
gut results in a lower rate of infection versus intravenous
feeding. Over the past two decades, researchers have tried
to elucidate reasons for the lower incidence of infection
between enteral and intravenous feeding. Several hypothe-
ses have been advanced.
One early hypothesis attributed the higher infection rate in

intravenous feeding to “bacterial translocation” – defined as
the passage of viable bacteria from the gastrointestinal tract
to extra-intestinal sites, such as the mesenteric-lymph-node
complex, liver, spleen and bloodstream. Promoting bacte-
rial translocation are three major mechanisms: 1. intestinal
bacterial overgrowth, 2. deficiencies in host immune
defenses, and 3. increased permeability or damage to the
intestinal mucosal barrier.11
The concept of bacterial translocation originated from stud-

ies conducted on rats fed a parenteral diet.12 The intestinal
mucosa of the rats degraded, resulting in a “leaky gut” char-
acterized by shorter villa, reduced cellular proliferation and
lower levels of mucosal protein.4 Theoretically, the break-
down of the intestinal mucosa provided a vehicle for bac-
teria to translocate from the gastrointestinal tract to the
mesenteric lymph nodes in other parts of the body. This
translocation hypothesis has been proposed to explain the
multiple organ failures and respiratory infections that occur
in critically ill or injured patients. Results from human trials,
however, fail to confirm the hypothesis.
74 Healthy Skin
Another hypothesis, which has presently gained References

1. Moore EE, Jones TN. Benefits of immediate jejunostomy feeding after major
more interest, involves the mucosa associated lym- abdominal trauma – a prospective randomized study. J. Trauma. 1986; 26:874-881.
2. Moore FA, Moore EE, Jones TN. TEN vs. TPN following major abdominal trauma –
phoid tissue (MALT).4 MALT is part of the immune sys-
reduces septic morbidity. J. Trauma. 1989; 29:916-923.
tem and consists of localized lymphoid tissue found in 3. Kudsk KA, Croce MA, Fabian TC, et al. Enteral vs. parenteral feeding: Effects on
septic morbidity following blunt and penetrating trauma. Ann. Surg. 1992;
various sites in the body, including the gastrointestinal 215:503-513.
tract, thyroid, breasts, lungs, salivary glands, eyes and 4. Kudsk KA. Beneficical effects of enteral feeding. Gastrointest Endosc Clin N Am.
2007; 17:647-662.
skin. MALT produces immunoglobulin A (IgA), which 5. Bengmark S. Enteral nutrition in HPB surgery: past and future. J Heptabiliary
protects both intestinal and extra-intestinal mucosa from Pancreat Surg. 2002; 9:448-458.
6. Kondrup J, Rasmussen HH, Hamberg O. et al. Nutritional risk screening (NRS 2002):
pathogens. a new method based on analyses of controlled clinical trials. Clin Nutr.
2003; 22(3):321-336.
7. Gonzalez-Huix F, Banares-Fernadez F, Esteve-Comas M, et al. Enteral versus
MALT is found in Peyer’s patches, located in the small parenteral nutrition as adjunct therapy in acute ulcerative colitis. Am J Gatroenterol
1993; 88:227-232.
intestine. Peyer’s patches are rich in immune cells including
8. Lochs H. To feed or not to feed? Are nutritional supplements worthwhile in
macrophages, dendritic cells, T-lymphocytes, and B-lym- active Crohn’s disease. Gut. 2006; 55:306-307.
9. Alsolaiman MM, Green JA, Barkin JS. Should enteral feeding be the standard of
phocytes – all of which are responsible for protecting the care for acute pancreatitis. Am J Gastroenter. 2004; 98:2565-2567.
intestinal mucosa. When an antigen stimulates T-lympho- 10. Sullivan DH, Bopp MM, Roberson P. Protein-energy undernutrition and life-
threatening complications among the hospitalized elderly. J Gen Intern Med.
cytes and B-lymphocytes in Peyer’s patches, the sensitized 2002; 17:923-932.
lymphocytes migrate to the mesenteric lymph nodes, where 11. Berg R. Bacterial translocation from the gastrointestinal tract. Trends in Microbiology.
1995; 3(4):149-154.
they proliferate. From the lymph nodes, the lymphocytes 12. Deitch EA. Bacterial translocation of the gut flora. J Trauma. 1990;30:S184-189.
pass into the bloodstream via the thoracic duct and travel 13. Breda S, Kudsk KA, Fukatsu K, et al. Enteral feeding preserves mucosal immunity
despite in vivo MAdCAM-1 blockage of lymphocyte homing. Ann of Surg
to the gut and other MALT-containing sites where they pro- 2003; 23(5):677-685.
14. Li J, Kudsk KA, Gocinski B, et al. Effects of parenteral and enteral nutrition on
duce IgA and destroy the offending antigen.
gut-associated lymphoid tissue. J Trauma. 1995; 39:44-52
15. Kudsk KA. Current aspects of mucosal immunology and its influence by nutrition.
Am J Surg. 2002; 183(4);390-398.
Supporting this hypothesis are animal studies, which show 16. Bengmark S. Enteral nutrition in HPB surgery: past and future. J Hepatobiliary
that a lack of enteral stimulation greatly reduces the pro- Pancreat Surg. 2002; 9:448-458.
duction of IgA.13,14,15 One such study, conducted by

Breda et al., demonstrates that when animals are fed par-
enterally with no enteral stimulation, they have a significant
reduction in mRNA specific for the production of MAdCAM- About the author
1 – a molecule involved in attracting B-lymphocytes and John J. Smith, PhD is principal with Cantaleir International Inc.,
T-lymphocytes to Peyer’s patches.13 The concomitantly a consulting firm that advises food, beverage, dietary supple-
lower production of MAdCAM-1 resulted in fewer lympho- ment and ingredient companies on innovation, technology devel-
opment, project management and product development related to
cytes and a reduction in the size of lymphocytes already
health and wellness. Dr. Smith was formerly with a Fortune-100
present. In broad terms, this hypothesis suggests that in
food and beverage company, where his work focused on
enteral feeding, use of the gastrointestinal tract, where 80
innovation and wellness products. You may contact him at
percent of the immune system is localized, activates the
jsmith@cantaleir.com.
immune system, accounting for the reduction in post-
surgical and other complications.16

COLOR BY
76 Healthy Skin
Special Feature
Carla Nitz, RN, BSN
Healthcare uniforms have come a long way since the days Building support
when registered nurses wore only white. Today’s nurses – The prospect of changing uniforms has the potential to be un-
and nearly all other hospital staff members – wear scrubs. And popular at first. We’re all creatures of habit, and change can be
because scrubs come in all different colors, patterns and uncomfortable. Another argument staff often raise is that uni-
styles, it can be difficult to differentiate a registered nurse from forms strip them of their individuality. Employees at the Med-
a respiratory therapist or a housekeeper. ical Center of the Rockies found a new way to express their
personality – with accessories! Kay Miller, the medical center’s
Staff members representing as many as 13 different disciplines vice president and chief nursing officer, said some nurses dec-
may enter a patient’s room each day, leaving the patient won- orate their name badges with cute pins, and others wear fun,
dering, just “who is my nurse?” It’s not uncommon for patients brightly colored shoes. In addition, the dress code allows staff
to report that “the nurse” gave them instructions, only to find to wear theme print tops underneath their scrubs for special
out later that it was a physical therapist or a dietitian. occasions such as Halloween and Christmas.
In an effort to improve patient care and satisfaction by making Similarly, at the Medical University of South Carolina (MUSC)
it easier for patients to identify their caregivers, many hospitals hospital in Charleston, S.C., staff can choose to wear either
across the country have converted to color-by-discipline uni- solid-color scrub tops and bottoms designated for their disci-
form programs. The color of the scrub uniform denotes the pline or solid-color bottoms with a print top. Registered nurses
discipline the healthcare professional represents. Patients and are also allowed to combine white with their color or print top.
staff are provided with a color key, allowing them to immedi- This decision was well-received and allowed staff members to
ately recognize each healthcare discipline according to the express their individuality.1
color they wear. At the Medical Center of the Rockies, in Love-
land, Colo., for example, nurses wear blue, lab employees When building support for your proposed color-by-discipline
wear black and radiology employees wear burgundy. program, introduce the idea gradually by generating discus-
Preparing your
Organization for
Color-by-Discipline
Uniforms
DISCIPLINE Improving Quality of Care Based on CMS Guidelines 77

sions at department meetings and through hospital memos Choosing colors

and newsletters. Many hospitals also appoint a task force con- It is important to choose colors that are flattering to most skin
sisting of representatives from all disciplines (e.g., nursing, tones and suitable for both men and women. Connie Yuska,
pharmacy, radiology, laboratory) to develop their color-by- vice president of clinical services at Medline, who implemented
discipline program. Goals for the task force might include: a color-by-discipline program while serving as chief nursing of-
ficer at a community teaching hospital in the Chicago area, rec-
• Communicating with other hospitals that have ommends allowing staff to vote for their uniform color. The task
implemented a color-by-discipline program force at her hospital narrowed the color choices to three per
• Reviewing relevant data from your hospital’s discipline and organized a voting process.
patient satisfaction surveys
• Researching colors and styles of uniforms Staff members at MUSC also voted on their uniform colors.
• Finding a vendor With guidance from the task force, each discipline selected a
• Revising the hospital dress code few color choices for voting. The different color scrubs were
• Choosing a target date for implementation displayed in the hospital lobby for two days. A Web-based vot-
of the new uniform program ing tool was developed giving all staff members the opportu-
Points to consider when choosing nity to vote on their color choice. Employees of each MUSC
a uniform vendor: discipline voted on their first, second and third choices.1
• Wide selection of uniform styles and colors
• Ability to have on-site sales several times a year At the Medical Center of the Rockies, Miller cut to the chase,
• Ease of ordering and distribution (online, and instead of voting, she had a representative from each dis-
in person, by mail) cipline draw a color from a hat on a first-come, first served
• Ability to customize scrubs with your facility logo basis. “We decided on that approach because choosing col-
ors was where we encountered the greatest bumps in the
process,” Miller said.
78 Healthy Skin
Support Staff
Housekeeping
Patient Transfer
Nursing (RNs)
Advanced Care Partners
Respiratory Therapy
Physical Therapy
Volunteers
Nursing Assistants
LOOK GREAT AND IMPROVE RESIDENT SAFETY AND SATISFACTION
WITH COLOR-BY-DISCIPLINE
SuiteStyles by Medline is a color-by-discipline uniform- With SuiteStyles you will also receive:
program that helps residents and family members • Scrubs sizing events to try on garments
quickly identify an employee by the color they are before ordering
wearing. In addition to the identification benefits, • Bag-by-name delivery - orders are individually
color-by-discipline helps to create a more professional, bagged, boxed by department and delivered to
coordinated look for the employees in your organization. each department
• Custom online store for employee reorders that
Think of how great your staff will look when they complements your unique uniform program
are visiting with residents and family members in a
coordinated color based on their role. The apparel
line features breathtaking colors and fabulous styles
designed to fit a wide variety of body types.
Facilities around the country are making the

change to create a more professional looking
staff. You can get started today by visiting
www.suitestyles.com to learn more and to
browse a sample online uniform store.
At MUSC patients and family members learn about the

Tips for Success! role-specific scrub schema via the GetWell Network, which
1. Views on uniform requirements are many and provides patients and families access to the Internet, enter-
packed with emotion. Be patient and listen to tainment, education and communications via their hospital-
staff comments. room television. A website was also developed to display the
2. Give all staff members a voice in selection of the scrub colors, frequently asked questions and the dress
uniform. Web-based voting is an effective and code policy.1
efficient method.
3. Set a short time frame for implementation and The Medical Center of the Rockies also includes the color
do not let the process take months to accomplish. coding information in all new employee orientation packets.
Deadlines longer than four months can add to
the opposition and a belief that the change will Positive outcomes
not occur. Change can be difficult for everyone, but if a uniform policy
4. Answer staff questions in a timely manner and allows for choice within parameters it can be very successful.
develop a communication tool such as an intranet Building consensus and including the staff in the decision-
site accessible to all staff members, keeping the making process will pay off in the end with a successful color-
process transparent. by-discipline program. It will also improve the professional
5. Provide each staff member with a one-time stipend appearance of your staff, improve your patient satisfaction
to aid in the purchase of their initial two sets of scores and contribute to an environment in which every
scrubs. Offer payroll deduction as an option to patient, physician and employee can identify the various
pay for additional scrubs. members of the healthcare team.
A lab employee at the Medical Center of the Rockies said the

color coding has helped her quickly identify other staff. On one
occasion, a patient asked her about a radiology procedure.
She did not know the answer, but then she spotted a person
in burgundy scrubs (radiology) walking down the hall. Even
though she did not know the person, she immediately identi-
fied their role, allowing the patient’s question to be answered
quickly and correctly.
Similarly, a cardiac nurse from the Medical Center of the Rock-

ies said color-coded uniforms allow her to quickly identify
which staff members are visiting her patients – even from down
the hall. If she sees a person in green, for example, she knows
Communication plan her patient is having his respiratory treatment. “The color cod-
Once your plan is finalized, you will need to communicate the ing really is a time saver,” she said. It also saves staff members
color-coding to staff, patients and visitors. Begin by sharing time getting ready for work not having to choose what to wear.
the revised dress code with staff about three months prior to
the conversion, recommends Yuska. Effective communication Although many staff members at MUSC were opposed at first
tools after implementation of the program are tent cards and/or to changing to the new dress code, a number of them later
posters in each patient room and throughout the hospital, voiced a change of heart. A psychiatric liaison nurse stated
showing which discipline each color represents and an that she was initially opposed to the plan and felt it would have
explanatory section in the patient admission packet. a negative impact on nurse retention.1
80 Healthy Skin
She now appreciates the ability to identify at a glance all of the

different healthcare professionals by the color of their scrubs.
As a consultant with responsibilities on units throughout the
hospital, she is now able to immediately identify the patient’s
nurse and other caregivers.1
At Yuska’s hospital, the implementation date went very

smoothly, and in fact, several nurses commented on the
improved professional appearance of the staff. In addition, on
the first day, a patient said he was so relieved to know that he
could instantly identify who the nurse on the floor was…he didn’t
have to guess. He told the manager that the color-coding gave
him a sense of comfort and security in an environment in which
he felt totally out of control.
“Patients want to know who’s in charge of their care. And

research shows that patients who are actively involved in their
own care and communicate with their healthcare team have a
safer, more satisfactory experience,” Yuska said. “The goal is
to help patients with identification and instill confidence that
they are being treated by an organized, professional team.”
For more information on Medline’s color-coded uniform Your Medline Doll Can Look
programs, visit www. SuiteStyles.com.
as Great as You Do!
SuiteStyles Nurse Scrubs
and Accessories Set
Brought to you by Medline’s SuiteStyles color-by-

discipline uniform program, you and your doll will
get noticed by the color you wear!
The doll scrubs and accessories set includes:

contrast trim top, drawstring pants, cardigan
jacket, stethoscope and Oxypas clogs. The set
will be available for sale in June 2010 at
www.medline.com/dolls.
Enter the following code at checkout for a

discount off your Medline Doll Nurse Scrubs
and Accessories Set: DOLL10 - 00022
Discount expires August 31, 2010.

Reference
1. Darby J. Thinking about changing your dress code. Gastroenterology Nursing.
2008; 31(4):295-296. Available at: http://www.nursingcenter.com/library/
journalissue.asp?Journal_ID=54035&Issue_ID=810887. Accessed April 1, 2010.

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Survey Readiness
MOUNT BAKER CARE CENTER:

PROACTIVE QUALITY ASSURANCE MEASURES HELP
IMPROVE RESIDENT AND FAMILY MEMBER SATISFACTION
By Janet R. Engel, Administrator
Our Nursing Home physical, speech and occupational

Nestled in the historic Fairhaven therapy as well as wound care,
District of Bellingham, Wash. pain management, IV therapy
Mount Baker Care Center is located and post-operative recovery for
on the east side of Bellingham Bay. individuals who require around-
At Mount Baker, we want to help the-clock care.
fulfill our residents’ desires for an ex-
pedient recovery and a high Our Challenge
quality of life. Our residents have a CMS is rolling out the Quality
number of activities to choose from Indicator Survey (QIS) in bands
each day to remain active and of five to six states over the next
stimulated, including arts and few years. The state of Washington
crafts, outings and specialized was part of the first group of states
Nursing Home: programs. Our community is selected by CMS to participate in
Mount Baker Care Center located in a picturesque area of QIS in late 2008 and adopt it as the
Bellingham Bay that is close to state survey of record. We were first
Location: shopping, parks, walking trails shown by our Medline
Bellingham, WA and a number of other independent account representative. He
senior apartments, mobile homes demonstrated how worked
Size: and condominiums. and explained that it covered the
70-bed skilled nursing same processes and quality
community with a wide Our 70-bed skilled nursing indicators as the QIS survey. We
variety of services across the community provides a true also learned that the same people
continuum of care, including continuum of care for our residents who had designed the QIS survey
independent and assisted under one roof. We provide and were training the surveyors
living, skilled rehabilitation, independent and assisted living, had designed .
long-term care and skilled rehabilitation, long-term
outpatient therapy care and outpatient therapy. We It made so much sense to us to use
also offer specialty care services for something similar to what the state
Challenge:
residents who need it, including surveyors were now going to be
Prepare for the new Quality
Indicator survey and create
a process for continuous It made so much sense to us to use something
quality improvement similar to what the state surveyors were now
going to be using in our state and nationwide.

using in our state and nationwide.

To make sure we were ready for
QIS, we decided to use to
prepare for the state survey and
discovered that it was an excellent
tool for helping with ongoing
quality assurance as well.
The Solution
We signed up for in
October of 2009 and immediately
started using it.
The user interface was very easy to

use, and we immediately did the
whole building in the first week.
We really liked that uses

similar programming and processes survey and discovered that conduct an assessment of that
as the QIS survey. When CMS it could also help us with our resident to develop their care plan
developed QIS, it wanted to create ongoing Quality Assessment and and we also do an assessment of
a structured, consistent way to Assurance (QA&A) process. CMS the resident using . This
measure compliance with federal requires every facility to have a gets us off on the right foot with
regulations from state to state and QA&A committee with at least the resident to understand their
from nursing home to nursing three staff members, the preferences, what they find
home. To do this, QIS covers a very director of nursing and a physician, acceptable and unacceptable in the
wide range of issues that are tied to which meets at least every quarter. areas of choices and helps us to
CMS regulations and interpretive The committee’s purpose is to communicate with their family.
guidance. CMS can’t talk to every identify quality issues and address
resident, family member and nurs- those issues. (The QA&A Not only do we do an initial
ing staff member in the United requirements are detailed in F520). assessment, we also do another
States, so it infers whether nursing assessment 30 days later. This gives
homes are meeting its guidelines Since the survey, we’ve decided to residents a chance to become
through the survey process. incorporate into our familiar with the facility and start
ongoing continuous quality thinking about their life here and
By using , we hoped it would assessment process. When we have the things that are important to
help us prepare for our annual a new resident at the facility, we them as a resident.
When we have a new resident at the facility, we conduct an

assessment of that resident to develop their care plan and
we also do an assessment of the resident using .
84 Healthy Skin
We also sent out an updated family During our quality assurance process with , we
survey. But we didn’t get as many
involved all of our key staff members—case managers and
surveys back as we had hoped. We
believe the new questionnaire that floor nurses, social workers, the activities team and our
we developed from is a
rehab coordinator—and we asked them all the questions
better tool than what we previously
sent to family members. that they might be asked during an actual survey.
We also learned about the
differences between QIS and
traditional state surveys, and the happening because we were very Overall, took a lot of the
role of resident, family and staff well-prepared. Everyone felt stress out of the state survey
interviews. We discovered that QIS comfortable because they had an process. It reduced the stress for
took different tracks depending on idea of what was going to happen the staff because they knew what
the cognitive state of the residents, during the QIS survey. The questions they were going to be
which we thought was very surveyors even commented on how asked. We had already been through
important. And it helped us well-prepared our staff was. With the entire process with , so
prepare for the observational , our staff got to know the we knew quickly what was needed
aspects of the survey. residents even better than they had and how to respond when the
in the past and they were able to actual state surveyors arrived for
We prepared for the resident answer questions from surveyors. our first Quality Indicator Survey.
observation aspect of QIS by
playing the role of observer During our quality assurance Going Forward
ourselves. In QIS, not only do the process with , we involved We’ve always sent out surveys to
surveyors ask residents questions all of our key staff members—case family members of our residents to
about the quality of their care at the managers and floor nurses, social get their feedback. Now, we’re using
nursing home, the surveyors also workers, the activities team and to help with our outreach to
observe the residents. We did our our rehab coordinator—and we family members. The QIS family
own observations to make sure asked them all the questions that interview is captured in ,
things were orderly. We now take they might be asked during an and we are using those same
extra care to monitor these areas as actual survey. questions as part of our family
part of our process with residents. survey. QIS asks family members
For QIS, there are a number of about 17 different aspects of the
documents to provide to the resident’s experience. We now ask
Results surveyors immediately, and questions about those same aspects
We used not only to prepare additional documentation that’s of the resident’s experience, because
our residents and their family required within one hour and we know that these issues are
members, but also our staff. We within four hours of the entrance important to both the resident
have a great staff, and because we conference. They ask for the and their family. The family
had been doing staff surveys resident census, facility floor plan, interview asks about a number of
through they knew what staff schedules and the list of important quality of care and
to expect. residents on ventilators or dialysis. quality of life considerations such
Because we had used , as privacy, personal property and
In our first QIS survey, our staff everyone on our staff knew where personal funds, the exercise of
members felt calm and confident to find all of our key documenta- rights and choices in sleeping
about the survey as it was tion that the surveyors required. and bathing.

is not only a survey readiness

tool, it is an ongoing QA system.
Sometimes with our residents, there
may be a change in status—in terms The Stage I Suite examines 125 resident-centered indicators
of their cognition and also their of quality of care and quality of life that are used to identify care areas
views may change. We need to be for a Stage II in-depth investigation and possible citations during a QIS.
on top of those changes. We don’t These indicators are contained in six modules that replicate exactly
always hear everything that’s the QIS assessments conducted on site during the survey, plus
one module that uploads and reviews MDS data. The modules are:
a concern and there are a lot of
things that change. We think it’s • Resident Interview • Family Interview
important to sit, side-by-side, and • Staff Interview • Resident Observation
ask questions. • Census Sample Record Review • MDS Data
• Admission Sample Record Review
For our long-term care residents, we
have a care conference at least once
a year, unless there is a significant
change in the resident’s health. If
that is the case, then we will meet
more often. At the care conference,
we hand the family members our
questionnaire, which is based on the
Quality Indicator Survey and
. We find that it’s an ideal
time to document and get feedback
from the family members.
To stay in compliance, you must

conduct quality assurance on an
ongoing basis. It’s great to have
a report, which we generate
from , to give to staff
members and ask them to correct
problematic areas.
This module report (similar to the one Mount Baker uses)

shows where a facility rates relative to the survey thresholds in the 125 quality of care
and life indicators based on the same logic that is used in a QIS survey.
ABOUT THE AUTHOR – Janet R. Engel is the administrator for Mount Baker Care Center in Bellingham,
Wash. a 70-bed licensed skilled nursing facility and 34-bed assisted living facility. Ms. Engel has
been working with seniors and in long-term care for the past eight years, and spent eight years prior to that
working in corrections.
86 Healthy Skin
“ How do we improve
our resident and family-
centered quality of care
and prepare for QIS?
We use abaqis.”
Sherri Dahle, RN, DNS
Director of Nursing
Central Healthcare
LeCenter, MN
The new Quality Indicator Survey (QIS) for nursing homes That gives you a unique advantage in preparing for your
is more resident-centered, with more information obtained survey – and in meeting your resident’s needs.
from direct questioning of residents and families. In fact,
60 percent of facilities have had more deficiencies in QIS abaqis® is sold exclusively through Medline.
than in the prior traditional survey, often in regulatory areas Learn more by signing up for a free webinar
such as quality of life that were not as fully investigated demo at www.medline.com/abaqisdemo.
in the traditional process.
abaqis is the only quality assessment and reporting

®
system for nursing homes that is tied directly to the QIS,

and its quality assessment modules reproduce the same
forms, analysis and thresholds used by State Agency
surveyors. Rich reporting capabilities on 30 care areas
guide you to what surveyors will be targeting in your facility.
EDUCATIONAL OPPORTUNITIES
FOR LONG-TERM CARE PROFESSIONALS
Making Sense of the New Quality Indicator Survey

Two free online courses available at www.medlineuniversity.com
The Role of the CNA in Understanding the

Resident-Centered Care and the Quality Indicator Survey
New Quality Indicator Survey
Designed for: Long-Term Care Administrators
Designed for: Nurses and CNAs
You’ll earn: One Administrator Credit
You’ll earn: One Continuing Education Credit*
Approved by the National Association of
This course covers: Long-Term Care Administrator Boards (NAB),
• How the state survey process has evolved this course covers:
into the new Quality Indicator Survey (QIS) • How the Quality Indicator Survey (QIS)
• The importance of the CNA in QIS and process evolved to standardize state surveys
resident-centered care in accordance with federal guidelines
• The different aspects of QIS, including the • The top six objectives of the QIS
resident interview, resident observations • How surveyors in all states are being trained
and family interviews in a structured and consistent manner
• How the CNA can help improve the overall • How the QIS differs from traditional
quality of care in long-term care facilities state surveys
* Courses approved for continuing education by the Florida Board

of Nursing and the California Board of Registered Nursing.
88 Healthy Skin
LEARN MORE ABOUT THE ONLY INTEGRATED SOLUTION

FOR SURVEY READINESS IN NURSING HOMES
Quality Assurance
System Webinar
This webinar gives a QIS overview and demonstration on how the abaqis® system can
help prepare for both the traditional and QIS survey processes. This demonstration also
highlights how abaqis® provides:
• Rich reporting capabilities to identify which care areas to target for
quality improvement
• Root cause analysis on a facility-wide or individual-resident basis, enabling
prioritization and focusing of interventions for maximum impact
• Emphasis on information reported by residents and families to help identify
the needs of residents, aiding your efforts to improve consumer satisfaction
Now with the new Stage 2 module featuring:

• A dashboard view of triggered care areas based on data collected
using abaqis® Stage 1 Suite
• Investigative tools to determine deficiencies in triggered care areas
Free Webinar at www.medline.com/abaqisdemo

90 Healthy Skin
Caring for Yourself
Win-Win
Negotiation
Wolf J. Rinke, PhD, RD, CSP
Times are tough, and virtually all of us have a need to get more “bang for our
How to buck,” whether it’s when we want to make a purchase, attempt to get a promo-
tion or talk our children out of getting that expensive “must-have” new toy. And
get more yet most of us consider negotiating or “haggling” a distasteful activity that should
be avoided at all costs. That is especially true if you are a woman. Research
shows that women are far less likely to negotiate than men, and when they do,
of what they do it in a way that is less assertive. One study found that 20 percent of
women do not negotiate at all. To help you overcome the distaste for negotiation,
you want master the following strategies, and you will get more of what you want.
Manage Your Perceptions

Lots of people lose in negotiations because they don’t manage their perceptions.
For example, have you noticed that when you’ve tried to sell your house, there
seemed to be houses for sale everywhere? Conversely, when you were looking
to buy a house there were virtually none to be found? That happens because of
selective perception—whatever we focus on, we tend to find.
Similarly, how many times have you interviewed for a job and felt the prospective
employer had all the power because you really needed the job while the employer
appeared to have all the applicants in the world? Having been in both roles—
interviewer and applicant—let me assure you nothing could be further from the
truth. The employer almost always needs you just as much as you need him (as-
suming of course you have the right skill set), even during these tough times.
These biases come about because you are committing an “attribution error.” For
example, because the employer has certain visible attributes of power you
assume she has more power than you do which, right or wrong, becomes
your “reality.”

In other words, your perception controls your reality, which in

turn impacts how you negotiate. For example, back to buying
that house. If you perceive that there are very few houses on
the market you will feel compelled to make a quicker and
potentially higher offer than if your perception is that there are
lots of houses on the market. The same is true when you are
interviewing for a job. If you assume that the employer has all
the power, then you are going to be negotiating from a
position of weakness and you probably will compromise
your expectations.
So the first step in every negotiation is to manipulate your per-

ceptions and “do a positive number on yourself” by convinc-
ing yourself that you deserve to have your needs met. In other
words, you define an empowering positive self-fulfilling Know Your BATNA, WAP and ROSA
prophecy that at a minimum equalizes the perceived power BATNA – Best Alternative to a Negotiated Agreement – is a
between you and the other party. Of course, it is even better concept developed by Roger Fisher and William Ury, authors
if you can convince yourself you have more power than the of Getting to Yes. Negotiating Agreement Without Giving In,
other party, which is quite feasible since you are always in one of the most popular negotiation books ever written. Ac-
control of your own perceptions. (If you would like help with cording to them, BATNA “is the standard against which any
this, devour my Make It a Winning Life book available at proposed agreement should be measured.” For example, if
www.WolfRinke.com.) I’m negotiating with a client for a consulting contract I have
priced at $95,000/year, my BATNA may be $95,000 if I value
Be Willing to Walk Away my free time more than the $95,000. Or it may be $45,000 if
Being able to walk away is the single most important concept I need the money to pay my mortgage, have very little work in
to internalize if you want to get more of the things you want! the pipeline, and could hope to generate about $45,000 from
Anytime you want something so bad you are not willing to writing another book in case I do not get the contract. Ac-
walk away, it is extremely likely you will become a deal taker cording to Fisher and Ury high quality negotiation is only pos-
not a deal maker. sible if you know your BATNA, since it is the only way you can
protect yourself from accepting unfavorable terms or from re-
For example, Superwoman—that’s my wife of over 40 years— jecting a minimally acceptable deal.
and I are avid cross-country skiers, hikers, bikers and mush-
room hunters. So approximately four years ago we found this A WAP or Walk-Away Price, also known as the reservation
super idyllic resort in Canaan Valley, West Virginia. We fell in price, “is the least favorable point at which one will accept a
love with a unit that was perfectly decorated and had an awe- deal.” A CEO I coach wanted to sell his business. A protracted
some view. We just had to have it. As a result, when it came long negotiation ended up with what I thought was a very
time to negotiate price, we were not willing to walk away, and sweet deal--$23.5 million for the business and the opportunity
we ended up paying full price. to start a new online business with financial support from the
92 Healthy Skin
new owners. The CEO had established a WAP of $26 million

and his BATNA was that he was going to continue to run his
business as he had in the past, and be open to other offers as
they were coming along. Although I thought it was a very fair
offer, he walked away from it, which he would probably would
not have done if he was not very clear about his WAP and
BATNA. He sold that business several years later and got a
much better deal.
ROSA is your Range Of Satisfactory Agreement. “It is the area

or range in which a deal that satisfies both parties can take
place.” For example, let’s say that you want to buy a used car, Negotiate Over Interests, Not Positions
which has a sticker price of $2,900. The seller says to himself, Let’s look at a father-daughter encounter.
I will not take less than $2,400. That’s the seller’s WAP, which Father: “Drink your milk.” (That’s his position).
usually is not known to the buyer. On the other hand, you say Daughter: “I don’t like milk.” (That’s her position).
to yourself, I will not pay more than $2,700. That’s the buyer’s
WAP, which is usually not known to the seller. The ROSA in Of course, from here on, it all goes downhill. So if the father is
this case is the area from $2,400 to $2,700. All other things a “Tough Battler,” he might say: “I’m your father and you will
being equal, an agreement should be feasible between listen to me,” or “I’m smarter than you,” or “I’m wiser than
$2,400 and $2,700. you” etc; “Now, damn it, drink your milk, or you will be
grounded!” (Win-Lose.)
If you handle this purchase like a distributive negotiation, (i.e.,
Win-Lose or Lose-Lose, your conversation might go some- If the daughter is a “Tough Battler” as well, it might go something
thing like this: like this: “I hate milk. If you make me drink it I will throw up.”
You: This car has quite a few dents and a lot of mileage.
I’ll give you $2,200. Even though on the surface it might appear that the father has
Seller: Thanks, but since that is way below the all the power, it’s likely that in this case the daughter will win;
“Blue Book” value I’ll wait until I get a better offer. after all, the father is probably not particularly keen to clean up
You: I’m sure you’d like to get it sold and I don’t really her vomit (Win-Lose).
like to haggle. I’ll give you $2,400, take it or leave it.
Seller: $2,600 and it is yours. Of course, the father could compromise with his daughter: “I
You: I tell you what, let’s just split the difference. I’ll tell you what, just drink half of your milk, and I’ll forget you are
give you $2,500. being so nasty to your old dad.” (Lose-Lose.)
Seller: You got yourself a deal.
If all else fails, he might bribe her: “If you drink your milk, I will
In this case, even though both parties compromised (Lose- take you to the movies.” (Of course, that is reinforcing various
Lose), they probably feel pretty good about the deal because undesired outcomes, such as: “If I rebel, good stuff happens.
they both got a better price than their WAP. So next time I can’t get what I want, I’ll just rebel.”)

Putting those unanticipated outcomes aside, all of these Separate Option Generation from Decision-Making
approaches will likely end up in either Win-Lose or Lose-Lose As you learned from the previous example, most of us tend to
outcomes, which neither the father nor his daughter are going focus on two mutually exclusive outcomes: either you get
to be particularly happy with. what you want and I lose, or I get what I want and you lose.
(Win-Lose.) If instead we learn to get in the habit of engaging
Now let’s take a look at how this might work if we focus on the brain power of both parties, many not-so-obvious ideas
interests, needs or wants instead of positions. can be generated that will meet or even exceed both parties’
Father: “I understand you don’t like milk. So please needs (Win-Win.). In other words, if we separate option gen-
tell me what you really want.” eration from decision-making, we can almost always make
Daughter: “I want food that tastes good, and milk just the pie bigger, and if we can’t, then we can establish objec-
doesn’t taste good to me.” tive criteria before attempting to reach an agreement (see the
Father: “I appreciate that. Now let tell you what I want. next section). Unfortunately, we tend to fall into the trap of
I would like you to get food that is nutritious and skipping the option generation step because most of us want
high in calcium. Why don’t we take a moment to get the negotiation process over with, and one way to do
and come up with a list of foods that meet both that is to come up with the answer
of our needs.” (This is separating option genera- both of us can agree on as fast
tion from decision-making. See the next section). as possible.
At this point, the father and daughter will probably be able to

come up with a long list of foods that meet both of their
objectives – food that tastes good, is nutritious and high in
calcium – such as cheese, ice cream, yogurt, pizza and the list
goes on. (Win-Win.)
In the Win-Lose approach, we saw how the parties’ egos

became identified with their position. Once that happens, the
negotiators have a new interest to satisfy – such as saving
face – which has nothing to do with the original interests. As
you discovered, the longer the parties attempt to reconcile
positions, the less attention they will devote to addressing their
real concerns, needs or wants. The result is it takes longer; it’s
likely to raise people’s negative emotions such as anger, and
is less likely to generate a Win-Win outcome. Plus, it will likely
damage the relationship between the bargaining parties.
94 Healthy Skin
At this point you might be saying: “That just doesn’t make any If All Else Fails Resort to Objective Criteria
sense.” Going back to the used car selling example, the only You will of course encounter real “fixed pie” scenarios. For
thing both parties are concerned with is price! Not necessar- example, if you have only one vacancy in your department
ily! It’s likely that both parties had other things that factored and there are three people applying, even after all the best ne-
into the sale. For example, if the buyer had said to the seller: gotiations in the world, there will still be two losers and only
“Before we talk about price, tell me what you want out of this one winner. To improve negotiation whenever you are involved
deal.” The seller might have said, “I’m interested in selling the in a true distributive negotiation process, where one party
car now, but keeping it for another two weeks because my must lose and the other win, it is wise to resort to objective
daughter’s new car won’t be delivered until then.” She might criteria such as standards, rules, independent mediators,
also have said, “I would like to get cash so I don’t have to arbitration, flipping a coin, drawing straws or other forms of
worry about a bounced check.” Or she might have said, “I chance, or any other criteria that produces a perceived fair
love this car like my own child and I would really like to sell it outcome. The classical example of this is the challenge of
to someone who will take really great care of it.” dividing one piece of cake between two siblings. If you have
children, I’m sure you can identify with this dilemma, and you
The buyer, on the other hand, might have said: “I would like to may remember how much potential bickering can ensue.
make sure I’m not buying a lemon; I would like a car that has There is of course a very elegant solution to that problem,
been well taken care of; I would like to drive it away today; I which dates back to biblical times. Have one child cut the
would like to deal with someone I can trust”…and the list goes cake and the other choose the piece she wants.
on. All of these may have economic value to either the seller
or the buyer and hence could have been used not only to in-
fluence the purchase price of the car, but could have resulted
in both parties getting far more than just a good price, i.e.,
getting a Win-Win outcome.
In the case of hiring a new employee, perceived fairness is

enhanced if you make the selection criteria and the selection
process public. There are other situations where it may be
beneficial for both parties to resort to objective criteria. Let’s
say for example, your best friend is interested in purchasing
your car. In this case, both of you express a desire to arrive at
a fair price without haggling because your relationship is more
important than getting the best price. As a result, you both
agree not to negotiate the price at all and instead abide by
the “Blue Book” value.
According to Fisher and Ury, there are three basic strategies

that will make resorting to objective criteria work:
1. Frame the proposal as a joint search for
objective criteria. In the case of selling our car to
your best friend, you both decided the “Blue Book”
value would represent a “fair” price for the car.
2. Reason and be receptive to the other person’s
reason regarding which standard is most applicable
and should be used to arrive at a “fair” outcome.
If you are selling your house, you may propose to
use an average sales price of three similar houses
that have sold in your neighborhood during the past
year as the “fair” price. The buyer, however, prefers
an average of three independent appraisals as a fair
price. In this case, it’s important to be receptive not
only to the proposal but also the underlying reason
for the proposal.
3. Don’t yield to pressure, yield to principles.
Pressure may come in a variety of forms: bribes,
About the author
side payments, threats or a refusal to budge. If the Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader,
other side uses these types of pressures, ask him to management consultant, executive coach and editor of the free elec-
tell you the reasoning behind his proposal, suggest tronic newsletters Make It a Winning Life and The Winning Manager.
To subscribe go to www.WolfRinke.com. He is the author of numer-
legitimate objective criteria and state why they
ous books, CDs and DVDs including Make It a Winning Life: Suc-
represent a fair outcome to both of you. If the other cess Strategies for Life, Love and Business, Winning Management:
party can’t do that, stick to your guns, and if that 6 Fail-Safe Strategies for Building High-Performance Organizations
fails you still have the option to ... you guessed it and Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to
Improve Your Leadership Effectiveness. All are available at www.Wol-
. . . walk away.
fRinke.com. His company also produces a wide variety of quality pre-
approved continuing professional education (CPE) self-study courses
© 2010 Wolf J. Rinke including Win-Win Negotiation: Fail-Safe Strategies to Help You Get
More of What You Want, on which this article is based, available at
www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
96 Healthy Skin
Snug-fitting sheets
for healthier skin.
SoftSpan sheets with spandex fit snugly
on the bed to comfort and protect the skin.
A patented blend of cotton, polyester and spandex
provides softness and a non-abrasive surface, along Call your Medline representative or 1-800-MEDLINE
with better air circulation for skin health. to trial two dozen SoftSpan fitted sheets for the
same price you’re paying for your current sheets.
Independent laboratory studies1 showed that SoftSpan
fitted sheets had 260% stretch in the width and 98%
stretch in the length, compared to a regular knit sheet,
which has 104% stretch in the width and 45% in the
length. Regular woven sheets have no stretch at all.
References
1. Diversified Testing Laboratories, Inc. ASTM D 6614-07, “Standard Test
More stretch means a tighter, smoother fit, and no Method for Stretch Properties of Textile Fabrics – CRE Method.” July 29,
wrinkles. Mayo Clinic and other healthcare experts 2009. Data on file.
2. Mayo Clinic. Bed sores (pressure sores). Available at http://www.may-
recommend keeping the bottom sheet pulled tight oclinic.com/health/bedsores/DS00570. Accessed on February 5, 2010.
to prevent wrinkles and bunching, which can cause 3. Oregon Department of Human Services. Pressure Sores: A Self-Study
Course. 2008. Available at: http://www.oregon.gov/DHS/spd/provtools/nurs
pressure that contributes to skin breakdown.2,3
A world without breast cancer is in our hands.

Medline’s Generation Pink latex-free, patented third-generation vinyl
exam gloves have the comfort, barrier protection and price you love.
Even better, when you choose Generation Pink gloves, you’re helping
Medline support the National Breast Cancer Foundation.
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PINK6077 XL 90/bx, 10bx/cs
To watch the “Pink Glove Dance” video and order Medline’s

Generation Pink Gloves, go to www.pinkglovedance.com
©2010 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark
of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Introducing Deb!
Starring in “The Pink Glove Dance”
Deb is the coolest person to dance the Pink Glove

Dance while at the same time skillfully caring for
patients, especially those battling breast cancer.
In her Generation Pink Gloves, pink bouffant cap

and scrubs, she energetically raises awareness
for the “Together We Can Save Lives Through Early
Detection” campaign. To order the Deb doll visit
www.medline.com/dolls
Take an online tour of

the booklet and view the
entire doll collection, visit
www.medline.com/dolls
Introduced in 2005, the Medline Doll Collection was created to recognize the caring and dedicated
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who made her debut in March 2010.
Healthy Eating
Nutrition
Information
Servings: 8
Calories: 79
Fat: 3.3 g
Sodium: 273 mg
Fiber: 3.1 g
Syrian Salad (8 servings)

¥ 1 head romaine lettuce ¥ 2 scallions, chopped Dressing:
¥ 1 cucumber, thinly sliced ¥ 1 small red onion, sliced ¥ ¼ c. olive oil
¥ 5 radishes, thinly sliced ¥ 3 oz. feta cheese, sliced or crumbled ¥ Juice of 1 lemon, or 3 tablespoons
¥ 1 red bell pepper, seeded and sliced ¥ ½ cup fresh parsley, coarsely chopped lemon concentrate
¥ 1 green bell pepper, seeded and sliced ¥ Several black olives ¥ 1 tablespoon wine vinegar
¥ 2 large tomatoes, cut into wedges ¥ 2 tablespoons capers (optional) ¥ 1 clove garlic, pressed or minced
¥ Salt and pepper, to taste
Directions: She encourages experimenting with different ingredients and

Rinse the romaine, tear into bite-size pieces and put into salad herbs. ÒAdd a little more garlic and different herbs. Fresh herbs
bowl. Arrange other vegetables attractively over the romaine, are always better than dried.Ó
topping with the feta, parsley, olives and capers. Combine the
dressing ingredients and drizzle over the salad. Vicki applies those same principles to
other recipes as well. ÒI tend to do a lot
Vendor data analyst Vicki Mirshak, who works at MedlineÕs with chicken, trying different herbs and
Vernon Hills, Ill., office, won a silver medal for this recipe in the spices and different cooking methods Ð
International Cookoff during Employee Appreciation Week 2008. poaching, grilling, baking. ItÕs best to stick
with a basic recipe, and then add a little to
ÒThis is a light, very easy-to-make salad thatÕs very nutritious. ItÕs it here and there to change it up.Ó
especially good for people who are watching what they eat,Ó
Vicki said.
100 Healthy Skin

FORMS & TOOLS
The following pages contain practical tools for implementing

patient-focused care practices at your facility.
Incontinence Care
Bilingual Application Guide – Adult Brief ..............103
Urinary Continence Assessment
& Implementation Form ..........................................110
Pressure Ulcer Prevention

Reducing Pressure Ulcers – for CNAs ..................105
Wound Photography
Wound Photography Validation Checklist ..............108
Photography Consent Form ..................................109

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING
Each package is a 2-Minute Course

in Advanced Wound Care ™
Medline’s Educational Packaging offers all the information you need, step by step,
short and sweet, to help the Medline dressing do its job of healing.
For more information visit www.medline.com/ep.
Application Guide/Bilingual Forms & Tools
Note: When applying hook tabs,

7ffb_YWj_ed =k_Z[ gently press down on the tab and
pull back slightly for a more
7Zkbj 8h_[\ secure attachment.
1. Fold the product in half lengthwise with the backsheet facing to the outside.
Doble el producto longitudinalmente por la mitad con la superficie posterior encarada

hacia fuera.
2. While folded, insert or apply the product from the “front to the back.” During this
process, pull the product up into the perineal area centering it “front to back.”
Unfold, spread and center the product across the back-side.
Mantenga el producto doblado e introdúzcalo o apliquelo de delante hacia atrás. Durante

esta operación, lleve el producto hasta la zona perineal y céntrelo do delante a atrás.
Desdoble, estire y centre el producto por la parte posterior.
3. Unfold, spread and center the product across the front-side. Gently pull the skin of
each inner thigh downward or away from the perineal area allowing the leg cuffs to
move into the now exposed crease.
Desdoble, estire y centre el producto por la parte anterior. Con gran cuidado estire hacia abajo
o retire de la zona perineal la piel de los muslos interiores permitiendo que los pliegues
internos del producto coincidan con el pliegue que ha quedado visible.
4. Apply the upper tabs while pulling the back wings snugly over the front wings.
Apply the lower tabs at a slight upward angle, while tucking the front wings smoothly in
and under the back wings. Smooth out all the wrinkles and folds while checking the
fit of the product. Adjust as required.
Aplique las cintas de cierre adhesivas superiores y estire simultáneamente las alas posteriors
de forma que ajusten perfectamente sobre las alas delanteraras. Aplique las cintas de cierre
adhesivas inferiores de modo que se forme u ángulo ligeramente hacia arriba e introduzca al
mismo tiempo las alas delanteras ligeramente por debajo de las alas traseras. Alise las
arrugas y pleigues que se hayan formado mientras comprueba la colocación del producto.
Ajústelo según sea necesario.

Forms & Tools Application Guide/Bilingual
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104 Healthy Skin

Reducing Pressure Ulcers – For CNAs Forms & Tools
Reducing Pressure Ulcers

Why is reducing pressure ulcers important?
A pressure ulcer or bed sore is an injury to the skin caused by constant pressure over a bony area
which reduces the blood supply to the area. Nursing home residents who cannot easily reposition
themselves are often susceptible to this condition and need special care. Pressure ulcers can be
dangerous and painful for a resident, in part because broken skin can allow infection into the body.
If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to
heal or may not heal at all. Sometimes, pressure ulcers can lead to death.
The presence of pressure ulcers limits the quality of life for a resident as evidenced by:
• Decrease in bowel and bladder function
• More incontinence
• Decrease in ability to move without help
• Decrease in mental capacity
• Increase in pain
• Increased risk for infection
• Less participation in activities
Proven techniques can reduce and almost eliminate this uncomfortable and potentially dangerous
condition. Advancing Excellence believes that “Nursing home residents receive appropriate care to
prevent and minimize pressure ulcers.”
How can nursing assistants help reduce pressure ulcers?
• Read residents’ care plans to learn who is at risk of developing pressure ulcers.
• Change the position of residents who are immobilized when in bed or when up in a chair.
• Provide frequent incontinence care. Remove urine and/or feces from the skin as soon as
possible.
• Provide water to the resident frequently because well-hydrated skin will not break down
easily.
• Check the resident’s skin each time you provide care. Note and report redness -- especially
over a bony area -- that does not disappear or a new open skin area.
• If the resident’s care plan requires a dressing, make sure it is there.
• Note the resident’s eating habits. Make sure they have nutritious meals. If residents aren’t
eating, notify the charge nurse.
• Look for opportunities to increase residents’ mobility through activities and/or socialization.
• Observe residents for pain, and notify the charge nurse if a resident complains of pain or if
you observe the signs of pain in non-communicative residents.
• Follow your nursing home’s facility’s protocols for pressure ulcer prevention and treatment.
• Participate in in-services related to pain.
• Talk to the charge nurse if you have a suggestion that you think might work better for a
resident.
• Share what you learn and know with other staff.
Advancing Excellence in America’s Nursing Homes is a national campaign to improve the quality of care
and life for the country’s 1.5 million people receiving care in nursing homes. Find out if your nursing home
is part of the Advancing Excellence Campaign. To sign up or get more information, go to
www.nhqualitycampaign.org.

Forms & Tools Reducing Pressure Ulcers – For CNAs
Pressure Ulcer Resources
Campaign Resources:
• Webinar: Reducing Pressure Ulcers in Nursing Homes: An Interdisciplinary Process
Framework http://www.nhqualitycampaign.org
• Video: Pressure Ulcers: Best Practices

http://www.nhqualitycampaign.org
• Implementing Change in Long-Term Care

• Campaign Goals and Objectives

• Top 10 Ideas to Involve All Staff in Advancing Excellence

Best Practice Resources:

• Preventing Pressure Ulcers: Evidence-based clinical practice guidelines that offer the latest
in the management of pressure ulcers emphasize an interdisciplinary team approach
http://www.ahcancal.org/News/publication/Provider/CaregivingAug2008.pdf
• Pressure Ulcer Plan Is Working

http://www.ahcancal.org/News/publication/Provider/CaregivingMay2008.pdf
Lessons Learned Resources:

• Getting A Jump On Wound Care: A wound care education program that empowers nurses
and CNAs is able to control pressure ulcers at a Colorado state veterans facility
http://www.providermagazine.com/pdf/2007/caregiving-01-2007.pdf
Links to Relevant Organizations:

• National Association of Health Care Assistants
http://www.nahcacares.org
• National Network of Career Nursing Assistants

http://www.cna-network.org
• Nursing Assistant Resources On The Web

http://nursingassistants.net
• American Association for Homes and Services for the Aged

http://www.aahsa.org/
• American Health Care Association

http://www.ahcancal.org/
• National Long Term Care Ombudsman Resource Center

http://www.ltcombudsman.org/
www.nhqualitycampaign.org
106 Healthy Skin

Forms & Tools Wound Photography Validation Checklist
VALIDATION CHECK LIST
Employee’s name_____________________________ Date____________

Reviewer’s signature__________________________
SKILL: PHOTOGRAPHING WOUNDS
Objective: The learner will be able to verbalize and demonstrate the photographing of a patient’s wound
Performance Criteria Criteria Criteria Comments

Met Not
Met
1. Explain purpose and procedure to patient
and caregiver
2. Review photograph permission form and

obtain written consent
3. Remove clutter from the area and adjust

the lighting if necessary
4. Gather necessary supplies
5. Prepare label with patient ID#, date,

body part
6. Wash hands, apply gloves and position

patient. Place drape in the background and
put label near the wound.
7. Remove the old dressing

8. Remove gloves, wash hands
9. Stand squarely and position camera
perpendicular to the wound
10. Take a minimum of 3 photos of
each wound:
a. From 4 feet to show wound location and
surrounding anatomy
b. From 2 feet to capture periwo. Zoom from
2 feet for close-up view
11. Do not touch patient’s skin with camera
or contaminated hands
12. Wash hands and complete wound
dressing
13. Document wound assessment and
photo descriptions in patient record
14. Print images, save file and place photos
108 Healthy Skin

Photography Consent Form Forms & Tools
AUTHORIZATION AND CONSENT FOR PHOTOGRAPHY AND PUBLICATION

The undersigned hereby authorizes _____________________________ (facility)
and the attending physician to photograph or permit other persons to photograph
_________________________(patient's name) while under the care of the above-
named facility.
The undersigned agrees that the above-named facility and the attending physician
may use and permit other persons to use the negatives or prints prepared from such
photographs for such purposes and in such manner as either may deem appropriate.
The undersigned agrees the photographs may be used for purposes including, but not
limited to, dissemination to hospital staff, physicians, health professionals and
members of the public for educational, treatment, research, scientific, public relations
and charitable purposes. This photography/filming is intended for the following
circumstances:
__________________________________________________________________
_
__________________________________________________________________
_
Dissemination of the photography/filming may be accomplished in any manner and
that such use is subject only to the following limitations:
__________________________________________________________________
_
The undersigned has entered into this agreement in order to assist scientific treatment,
educational, public relations and charitable goals and hereby waives any right to
compensations for such uses by reasons of the foregoing authorization, and the
undersigned and his/her successors or assignees hereby hold the above-named
facility and the attending physician and their successors and assignees harmless from
any or against any claim for injury or compensation resulting from the activities
authorized by this agreement
The term "photograph” as used in the foregoing agreement, shall mean motion picture
or still photography in any format, as well as videotape, video disc, electronic, audio
media and any other mechanical means of recording and reproducing images or
voice.
Date:______________ Time: ______ am/pm
Signature: ____________________ Signature of Witness: ____________________
If signed by other than patient, indicate relationship: Parent / Conservator / Guardian

Forms & Tools Urinar y Continence Assessment
URINARY CONTINENCE ASSESSMENT & IMPLEMENTATION FORM
Resident ________________________________________________________ Room #___________
Assessed by _______________________________________________ Date: ___________________

Resident ________________________________________________________ Room #___________
Current
AssessedProduct Information: Size: _____ Type: ______________
by ________________________________________ _______ Frequency of______________
Date: _____ Leakage: ________ times/week ❏ None
Current Product Information: Size: _____ Type: ______________ Frequency of Leakage: ________ times/week ❏ None
1. Determine Type of Incontinence

...............................................
Resident is continent N Y → proceed to section 2
Do you leak when you cough, sneeze, exercise, laugh? . . . . . . . . . . . . . . . . . . . . N Y → stress
→ urge
QUESTIONS
Do you need to rush suddenly to toilet? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y

Do you sometimes not make it to the toilet? . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y → urge
Do you urinate more than 7 times/day or 2 times/night? . . . . . . . . . . . . . . . . . N Y → urge
Do you have a weak stream of urine? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y → overflow
Do you have frequent dribbling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y → overflow
Do you have burning or blood in urine? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y → transient
Is the incontinence related to something other than urinary tract,
→ functional
CHART
such as inability to undo a zipper? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N Y

Does the resident have a postvoid residual greater than 200 cc? . . . . . . . . . . N Y → overflow
Does the resident take stool softeners, antipsychotic, anticholergenic,
narcotic analgesics, or other drugs that may affect continence? . . . . . . . . . . N Y → further evaluation may be necessary
PHYSICAL: FEMALE
PHYSICAL: MALE
Is there presence of pelvic prolapse or other abnormal Is the foreskin abnormal (difficult to draw back, reddened)?
finding? . . . . . . . . . . . . . . . . . . . . . .N Y → stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .N Y → transient
Is the vaginal wall reddened and/or thin? Is there drainage from the penis? . . .N Y → transient
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .N Y → transient
Is the urethral meatus obstructed?
Is there abnormal discharge? . . . N Y → transient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .N Y → overflow
Select (circle) the type of incontinence that most fits resident based on answers above:
Urge Stress Mixed Overflow Functional Transient
Sudden urge, large Leakage when Combination of Weak stream, Unable to get to Temporary or re-
amounts, can’t get coughing, standing urge and stress dribbling, toilet without cent onset,
to toilet in time up, sneezing symptoms incomplete voiding assistance (mobility) variety of causes
2. Determine Resident’s Voiding Pattern

Every resident should have a completed voiding diary upon admission and with significant changes in condition.
Voiding diary scheduled (date) ________________________ Date completed _______________________ Initials__________
Did the resident have a pattern? _______ For pattern, see voiding diary.
110 Healthy Skin

65528_MedCal-A:Layout 1 5/4/10 1:45 AM Page 2 65528_MedCal-B:Layout 1 5/4/10 1:46 AM Page 111
Urinar y Continence Assessment Forms & Tools

Join the team!
HEALTHY SKIN URINARY CONTINENCE ASSESSMENT & IMPLEMENTATION FORM
3. Evaluate for Behavioral Program

What is the MDS Score on B.4 (Cognitive skills for daily decision-making)?
If 0, 1 If 2, 3
What is MDS score on G1I a? Prompted Voiding or Scheduled Voiding
(ADL Self-Performance / Toilet Use)
Residents with the following conditions could still benefit from par-
ticipating in a prompted or scheduled voiding program:
If 0, 1 If 0, 1, 2, 3, 4 • Those who cannot feel “urge” to urinate
Pelvic Floor Rehab Prompted Voiding • Agitated or disoriented residents
Bladder Rehab Scheduled Voiding • Bedridden residents or those with mobility limitations
Based on above, the resident may be a candidate for ______________________________
Resident is not a candidate for a bladder program due to: ❏ Indwelling catheter ❏ Confusion/dementia Other ___________________
4. Catheterization
Catheter — Type __________________________________ Size: ____________________________
Medical Justifications:
■ Urinary retention that cannot be treated medically or surgically, related to:

• Post void residual volume over 200 ml
When it comes to hot • Inability to manage retention/incontinence with intermittent catheterization
topics in long-term care, • Persistent overflow incontinence
you’re the experts! • Symptomatic infections

• Renal dysfunction
■ Contamination of stage III or IV pressure ulcers with urine which impeded healing.
You, our readers, are on the front lines of everything that for writers and contributors. Whether youʼd like to try your
happens in the healthcare industry – and we want to hear hand at writing or offer suggestions for future articles, we ■ Terminal illness/severe impairments – which makes positing/changing uncomfortable or associated with intractable pain.
from you! Have you ever wished you could write an want to hear what you have to say! You never know – the
article that would be published in a large-circulation next time you open an issue of Healthy Skin, it might be
Notes:
magazine? Nowʼs your chance. Healthy Skin is looking to read your own article!
Contact us at healthyskin@medline.com to learn more!
Content Key
Weʼve coded the articles and information in this magazine to indicate which national quality initiatives
they pertain to. Throughout the publication, when you see these icons youʼll know immediately that
the subject matter on that page relates to one or more of the following national initiatives:
• QIO – Utilization and Quality Control Peer Review Organization
• Advancing Excellence in Americaʼs Nursing Homes
Weʼve tried to include content that clarifies the initiatives or gives you ideas and tools for implement-
ing their recommendations. For a summary of each of the above initiatives, see Pages 8 and 9.
Cover 65528 MedCal.indd 2 5/4/10 4:17 AM

VOLUME 8, ISSUE 2
Free Webinars Improving Quality of Care Based on CMS Guidelines
New Techniques for Pressure Ulcer Prevention,

Hand Hygiene and CAUTI Prevention
Free CE Inside!
Volume 8, Issue 2
PRESSURE ULCER PREVENTION IN LONG-TERM CARE
Learn more about continuous quality improvement for the prevention of avoidable pres-
sure ulcers and F-Tag 314 citations, factors leading to pressure ulcers in long-term care
facilities and comprehensive pressure ulcer prevention strategies and solutions.
JUNE
3rd 12:00 pm - 1:00 pm
10th 1:00 pm - 2:00 pm
J U LY
8th 1:00 pm - 2:00 pm
14 1:00 pm - 2:00 pm
AUGUST
12th 12:00 pm - 1:00 pm
18th 1:00 pm - 2:00 pm
SEPTEMBER
7th 11:00 am - 12:00 pm
9th 1:00 pm - 2:00 pm
WOUND
Photography
th
23rd 11:00 am - 12:00 pm 22 11:00 am - 12:00 pm 20th 11:00 am - 12:00 pm

nd
14th 12:00 pm - 1:00 pm
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HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES
As the number one defense against healthcare-acquired conditions, hand hygiene plays Choosing
HEALTHY SKIN
an important role in the prevention of infections. Learn how hospitals and healthcare
facilities are combining best-in-class products and education to achieve hand hygiene Nutritional
Supplements
compliance while dramatically improving the skin condition of healthcare workers.

14th 11:00 am - 12:00 pm 8th 11:00 am - 12:00 pm 17th 2:00 pm - 3:00 pm 2nd 11:00 am - 12:00 pm
17th 12:00 pm - 1:00 pm 21st 2:00 pm - 3:00 pm 23rd 1:00 pm - 2:00 pm 27th 2:00 pm - 3:00 pm
Sign up at www.medline.com/handhygiene SURVEY

INNOVATION IN THE PREVENTION OF CAUTI RESULTS
Join your colleagues from around the country to learn more about strategies to prevent
& Winners
catheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.
7th 11:00 am - 12:00 pm 7th 11:00 am - 12:00 pm 12th 11:00 am - 12:00 pm 1st 11:00 am - 12:00 pm
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11th 12:00 pm - 1:00 pm 8th 12:00 pm - 1:00 pm 16th 11:00 am - 12:00 pm 2nd 12:00 pm - 1:00 pm
18th 12:00 pm - 1:00 pm 20th 11:00 am - 12:00 pm 16th 2:00 pm - 3:00 pm 22nd 11:00 am - 12:00 pm
21st 11:00 am - 12:00 pm 20th 2:00 pm - 3:00 pm 25th 11:00 am - 12:00 pm 22nd 2:00 pm - 3:00 pm
22nd 2:00 pm - 3:00 pm 21st 12:00 pm -1:00 pm 25th 2:00 pm - 3:00 pm 27th 1:00 pm - 2:00 pm
EMBRACING
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NEW TECHNOLOGY
Hosted by Connie Yuska, RN, MS, CORLN iPhone App Just Launched at
www.medline.com
and Lorri Downs, RN, BSN, MS, CIC
All schedules are Central Daylight Time. www.medlineuniversity.com!

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65528_MedCal-B:Layout 1 5/4/10 1:46 AM Page 112

New Techniques for Pressure Ulcer Prevention,

23rd 11:00 am - 12:00 pm 22 11:00 am - 12:00 pm 20th 11:00 am - 12:00 pm

Sign up at www.medline.com/PUPP-webinar Guidelines

JUNE J U LY AUGUST SEPTEMBER

Sign up at www.medline.com/handhygiene SURVEY

and Lorri Downs, RN, BSN, MS, CIC

All schedules are Central Daylight Time. www.medlineuniversity.com!

Cover 65528 MedCal.indd 1 5/4/10 5:41 PM

Urinar y Continence Assessment Forms & Tools

HEALTHY SKIN URINARY CONTINENCE ASSESSMENT & IMPLEMENTATION FORM

3. Evaluate for Behavioral Program

■ Urinary retention that cannot be treated medically or surgically, related to:

you’re the experts! • Symptomatic infections

Contact us at healthyskin@medline.com to learn more!

Improving Quality of Care Based on CMS Guidelines 111

Cover 65528 MedCal.indd 2 5/4/10 4:17 AM

Editor Survey Readiness

Improving Quality of Care Based on CMS Guidelines 3

HEALTHY SKIN Letter from the Editor

For that reason, our first announcement is that we are

The Survey Results Are In!

Where you work Average amount of time 16 minutes

What you do Your biggest barriers to pressure

Your top three priorities Organizations involved 27%

Tur n the page to see the bonus question winners!

Improving Quality of Care Based on CMS Guidelines 5

Congratulations to our SURVEY WINNERS!

AHCA/NCAL CONGRESSIONAL BRIEFING

Da Center for Assisted Living (NCAL) are pleased to invite you to

e the our Congressional Briefing, June 8-9, 2010, in Washington, D.C.

We look forward to seeing you there!

To register for Congressional Briefing visit: cb.ahcancal.org

Two Important National Initiatives

QIO Utilization and Quality Control Peer Review Organization

Quality Improvement Organization Program’s 9th Scope of Work Theme

2 Advancing Excellence in America’s Nursing Homes

The 9th Scope of Work Content Themes

Clinical and Operational/Process Goals

Trends in Goal Selection

Participating nursing homes: 7,481

Improving Quality of Care Based on CMS Guidelines 9

Journal of the American College of Certified Wound Specialists (2009) 1, 109–113

‘‘Why Wet to Dry’’?

Prior to the 1960s, clinicians

Let’s begin with a quick quiz:

Improving Quality of Care Based on CMS Guidelines 11

Changing Philosophy cept of passive dressings began to change. Dressings were

Improving Quality of Care Based on CMS Guidelines 13

TenderWet ACTIVE GENTLY REMOVES

We’re confident you’ll find TenderWet Active more effec-

Improving Quality of Care Based on CMS Guidelines 15

‘‘Wet to dry needs to die!’’

BRINGING IT HOME TO YOU

That’s why Medline HomeCare is proud to offer innovative

To learn more about Medline HomeCare, call us at

How 4 square inches of Puracol® Plus

Look closely. It’s not a bandage. It’s Puracol Plus ™

MicroScaffold , made entirely of pure native collagen.

Chronic wounds tend not to heal when unbalanced levels

Advanced Wound Care.

Improving Quality of Care Based on CMS Guidelines 21

As always, you can also access courses online