Packets make assessments easy for nurses to perform

Nurses at Sullivan County Community Hospital Home Health and Hospice in Sullivan, IN, don't spend time looking for a copy of the Braden Scale, documentation checklists, pressure ulcer intervention guidelines, or teaching tools. They just pick up a pre-packaged envelope and go.

"The best way to make sure a nurse has everything necessary for a pressure ulcer assessment is to put it together ahead of time," says Paula J. Long, RN, CHCE, administrator of the agency. They have two pressure ulcer-related packets. One packet contains tools and information to use for patients who require a risk assessment for pressure ulcers, and the other packet is for patients who already have a pressure ulcer that requires treatment.

Contents of each packet are:

• Pressure ulcer risk assessment packet:

— Braden Scale;

— guideline for assessment of skin, lower extremities, medical conditions, medications, and other risk factors associated with pressure ulcers;

— guidelines for interventions based on risk factors, patients goals, and patient input;

— teaching protocol tool to use with patient, family member, or other caregiver;

— care plan with clinical goals.

• Pressure ulcer packet:

— process checklist that goes to pressure ulcer team manager and outlines actions and time frame;

— a fax physician communication form specifically for pressure ulcers that the nurse completes to include a description of the ulcer, treatment recommendations, nutritional status, and other information the physician will need to order treatment;

— weekly pressure ulcer record on which the nurse documents details of the wound and the treatment;

— intervention guidelines;

— care plan with clinical goals.