Welcome back to my series addressing sepsis and why it is important to your cases. Feel free to email me with any questions you may have regarding the information I have provided or if you would like some help with one of your cases.

Today we are talking about Pressure injury wounds and how the nursing standard of care applies to cases involving pressure injury wounds that develop into SIRS, infection, and sepsis.  This includes the standard of care for the LPN that works in a hospital or nursing home.

Paige Legal nurses know that elderly or bedridden residents/patients are at high risk for developing pressure injury wounds and therefore require attention to strategic preventative measures in their plans of care. This is nursing’s first line of defense in the prevention of pressure injury wounds.

Key standards:

• All new patients and residents are required to have a thorough skin evaluation upon admission
• A skin evaluation should then be done on a daily basis with care in the hospital: in the nursing home, an evaluation should be done when giving incontinent care to a resident.
• Any resident/patient at risk for skin breakdown should have a plan of care initiated with preventative interventions put in place.
• A stage II pressure injury wound has broken the skin barrier and is now considered high risk for worsening.
• Nursing standard of care requires preventative interventions be implemented immediately (if not already in place) once a resident is identified with active skin breakdown.
  • The medical team (and responsible party designated (RP) for a nursing home resident) be notified and the plan of care updated with appropriate interventions.
  • In a hospital setting a wound care consult would be expected.
• The Plan of Care is required to be updated with all new acute changes regarding pressure injury wounds
• A key indicator of a worsening stage II pressure injury wound is the development of slough. Slough is not present in stage II pressure injury wounds only in stage III pressure injury wounds and higher (slough may be present in other types of wounds such as vascular wounds, diabetic wounds, and other non-pressure related wounds).
• A wound care consult would be expected to evaluate and treat this worsening wound.
• A stage III, IV or unstageable pressure injury wound requires emergent preventative interventions to be implemented as well as notification of the medical team (and RP in a nursing home). Nursing would expect to see a wound care consult followed by treatment of the wound by a team of wound care providers.

A lot of LPNs work in nursing homes. LPN’s can participate in the care plan process of assessment, planning, implementation, and evaluation. They are then required to communicate the nursing component of the nursing care plan and all modifications of the plan to the members of the health care team.

Federal regulations require that registered nurses be employed by the nursing home in various supervisory roles requiring the RN to perform certain assessments. If the LPN frontline nurse sees an abnormality with a resident, they are expected to promptly notify the RN (or the medical provider team)  for a more comprehensive assessment.

CMS states that an RN with responsibility for the resident must be involved in the plan of care development. An RN is required to be involved in the care of the resident for at least eight consecutive hours a day, seven days a week. Federal regulations also require nursing homes to ensure that “licensed nurses” have the skillset necessary to provide care. CMS stipulates this skillset must include contributing to the assessment, evaluation, planning, and implementation of resident care plans.

It is important for nursing to consider the big picture, meaning to examine the skin surrounding the wound and to compare each wound assessment to the prior wound assessments and documentation.

• If an LPN is unable to accurately complete any part of a resident/patient assessment, the LPN would be expected to report to a supervisory RN to request an additional assessment of the pressure injury wound.
• If a staff RN nurse is not proficient or qualified to make these assessments, this strengthens the need for a wound care consult and treatment by a specialized wound care team.