Skin and wound care programs for LTC

Anyone who reflects on the current status of skin and wound care in long-term care (LTC) will certainly come to two apparent conclusions: Nurse aides (NAs) are the “eyes and ears” of skin and wound care, and practical nurses (PNs) often drive skin and wound care by following standard protocols or by faxing primary care providers (or their extenders) with recommendations for care that are then signed and returned to the facility for the PNs to carry out.

While the skin and wound care ideal may be to have interprofessional teams of healthcare providers doing rounds together weekly to view wounds and skin conditions, this is not yet the standard of long-term care in this country. Given the current healthcare economic situation, particularly in long-term care, it is unlikely that interprofessional wound and skin care teams will be expanding in long-term care anytime soon.

For the foreseeable future, skin and wound care may stay primarily as it is in LTC facilities, with NAs and PNs delivering and directing more of the hands-on, bedside care, often without the benefit of oversight by either registered nurses or physicians. If this remains the case, how can we optimize the skin and wound care expertise of NAs and PNs?

INSERVICE EDUCATION

Optimized skin and wound care regimens can improve resident outcomes, avoid citations and prevent lawsuits. LTC staff development personnel should train NAs and PNs in skin and wound care annually and retain written documentation of competency for each employee.

Several outstanding programs have been developed to do just that. The Senses Program from Healthpoint, Ltd., Fort Worth, Texas, targets NAs and shows how to use the five senses to prevent pressure ulcers. This program includes a CD, posters, handouts and pins. Medline Industries, Mundelein, Ill., developed the Pressure Ulcer Prevention Program (PUPP) in both NA and nurse versions. This program includes workbooks, competency tests, pins and certificates. More such programs for NAs and PNs are urgently needed to address all aspects of skin and wound care in long-term care.

LTC facilities should strive to reach the following goals:

• Annual documentation of skin assessment and care competencies by NAs and PNs
• Annual documentation of wound assessment and care competencies by NAs and PNs
• Accurate pressure ulcer staging and correct identification of skin and wound locations by PNs
• Understanding of the limits to their scope of practice by NAs and PNs (related to assessments and interventions based on statutory law)
• Annual documentation of the PNs’ ability to understand and implement the facility’s skin and wound care guidelines
• Mechanisms for NAs and PNs to train and round with wound care specialists
• Introduction of critical thinking exercises to teach PNs to contact primary care providers and their extenders for skin and wound care orders

ARE NA AND PN PROGRAMS TEACHING ENOUGH ABOUT SKIN AND WOUND CARE?

Prospective employers in long-term care should inquire as to how their future NA and PN staff members are being trained in their educational programs. Is the educational content up-to-date and in line with national standards of care for skin and wound care? Content varies a lot, not just from program to program, but from state of state.

LTC facilities should ask their local education programs the following questions:

For NAs:

• How many minutes of skin and wound care are taught in the NA Program?
• Are prevention strategies for skin breakdown and pressure ulcers reviewed?
• Do students learn about Moisture Associated Skin Damage (M1040H, Section M, MDS 3.0) and how to prevent and treat it?
• Are NAs empowered to be the “eyes and ears” of the skin and wound care team?
• Do NAs learn how to communicate their findings to other members of the interprofessional team?
• Are NAs taught how to interact with families when it comes to skin and wound care questions and concerns?
• Can you, as a potential employer, get documentation of the student’s skin and wound care competency?

For PNs:

• How many hours of skin and wound care are taught in the PN Program?
• Are prevention and treatment strategies for pressure ulcers reviewed?
• Are PNs taught to distinguish Moisture Associated Skin Damage (M1040H, Section M, MDS 3.0) from other skin and wound conditions?
• Are PNs taught to respect and value observations and input from NAs?
• How are PNs taught to document and communicate skin and wound conditions?
• Do PNs know when to notify a registered nurse or physician because the situation is beyond the scope of their practice?
• Can you, as a potential employer, get documentation of the student’s skin and wound care competency?

By posing these questions, long-term care facilities can positively impact NA and PN Education Programs.

IMPROVING THE FUTURE

Long-term care facilities are in a unique position to impact NA and PN education programs positively. By opening a dialogue with nurse educators about skin and wound care curricula, LTC providers can make their requirements known to nurse educators who can then review their curricula to ensure that employers’ needs are being met. Such collaboration will be a three-way win for students, employers and LTC residents.

Diane L. Krasner, PhD RN CWCN CWS MAPWCA FAAN, is a Wound & Skin Care Consultant and the Adult Nursing Coordinator, Adult Nursing Education Program at York County School of Technology in York, Pa. She is the lead co-editor of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals (www.cwc5.com). She can be reached at dlkrasner@aol.com

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