Skin Integrity Risk Assessment and Care Planning.pptx
advertisement
2/6/15 Prevention of Pressure Ulcers: Risk Assessment & Care Planning Jeri Lundgren, RN, BSN, PHN, CWS, CWCN VP, Clinical Consulting Joerns PEOPLE PASSION PERFORMANCE Confidential & Proprietary Regulatory F314: • Based on the comprehensive assessment of a resident, the facility must ensure that -– A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and – A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. PEOPLE PASSION PERFORMANCE Confidential & Proprietary Regulatory and Litigation The care setting must PROVE that the wound was….. PEOPLE PASSION PERFORMANCE Confidential & Proprietary 1 2/6/15 Regulatory & Litigation • Can the care setting prove: – Assessed for risk factors – Interventions correlate to individual risk factors – Implemented the plan of care – Evaluated the plan of care – Updated the plan of care with changes **NOT AS SIMPLE AS HAVING THE PHYSICIAN WRITE IT WAS UNAVOIDABLE!! PEOPLE PASSION PERFORMANCE Confidential & Proprietary Pressure Ulcer Definition Pressure Ulcers: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction7. PEOPLE PASSION PERFORMANCE Confidential & Proprietary Prevention Assessing for Risk of Skin Breakdown PEOPLE PASSION PERFORMANCE Confidential & Proprietary 2 2/6/15 Risk & Skin Assessment – Comprehensive Risk Assessment in LTC • • • • Upon Admission Weekly for the first four weeks after admission Change of condition Quarterly and annually with the MDS – Skin Inspection in LTC • Upon Admission – Imperative they capture wounds within the first 24 hours • Daily with cares by the nursing assistant • Weekly by the licensed staff • Upon a PLANNED Discharge PEOPLE PASSION PERFORMANCE Confidential & Proprietary Risk & Skin Assessment – Comprehensive Risk Assessment in Acute Care • Upon Admission • Daily • Upon discharge – Skin Inspection in Acute Care • Upon Admission • Daily • Upon discharge PEOPLE PASSION PERFORMANCE Confidential & Proprietary Risk & Skin Assessment – Comprehensive Risk Assessment in Home Care • Upon Admission • With each licensed nurse visit – Skin Inspection in Home Care • Upon Admission • With each licensed nurse visit PEOPLE PASSION PERFORMANCE Confidential & Proprietary 3 2/6/15 Risk Assessment Tools • Validated Risk Assessments – Use a recognized risk assessment tool such as the Braden Scale or Norton – Use the tool consistently – Regardless of the overall score of the risk assessment, assess each individual risk factor PEOPLE PASSION PERFORMANCE Confidential & Proprietary Risk Assessment Tools • No risk assessment tool is a comprehensive risk assessment – Braden • • • • • • Sensory Perception Moisture Activity Mobility Nutrition Shear and Friction – Doesn’t capture • Diagnosis • Medications • Resident Choice, etc PEOPLE PASSION PERFORMANCE Confidential & Proprietary Risk Assessment Tools • Overall goal is to identify the INDIVIDUAL risk factors and implement correlating interventions that modify, stabilize or eliminate the risk factors Problem Poten.al for altera.on in skin integrity secondary to: • Immobility due to right sided hemiplegia PEOPLE PASSION PERFORMANCE Goal Skin will remain intact Interven/ons: • Provide a pressure redistribu.on maDress • Provide a wheelchair cushion • Elevate heels with bilateral heel liF boots • Turn and reposi.oning q2 hours Responsible person(s) Nursing Confidential & Proprietary 4 2/6/15 Braden Scale • Note on the Braden Scale the lower the score the higher the risk – 15-18 At Risk – 13-14 Moderate Risk – 10-12 High Risk – 9 or lower Severe Risk Before utilizing the Braden please get permission at www.bradenscale.com PEOPLE PASSION PERFORMANCE Confidential &IProprietary Footer nfo Here 13 Breaking Down the Braden • Impaired Sensory Perception – Inability to feel pressure or pain to the skin/tissues • CVA, paraplegia, quadriplegia, etc. • Cognitive impairment • Neuropathy PEOPLE PASSION PERFORMANCE Confidential & Proprietary Braden Scale - Activity • Activity: – Decreased activity level leading to staying in one position for a long period of time • • • • Chairfast Bedbound Choosing not to get out of the bed or chair Chooses not to change positions PEOPLE PASSION PERFORMANCE Confidential & Proprietary 5 2/6/15 Braden Scale - Mobility • Mobility • Due to being unable to move or having limited movement leads to staying in one position for long period of time: • Diagnosis: CVA, MS, Paraplegia, Quadraplegia, end stage Alzheimers/Dementia, etc. • Fractures and/or casts • Cognitive impairment • Pain • Restraints or medical equipment • Choosing not to be mobile • Contractures PEOPLE PASSION PERFORMANCE Confidential & Proprietary Breaking Down the Braden • The interventions are basically the same for: – Immobility, – Impaired sensory perception, and – Decreased activity • All lead to inactivity/movement • Goal of interventions is to decrease or remove the pressure to promote circulation to the skin and tissues PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Restorative & Mobility Programs – Referral to Therapy and Restorative Nursing • Amputation/Prosthesis Care • Communication • Eating • Mobility • ROM and PROM • Self care training/ADLs • Toileting • Splint/brace PEOPLE PASSION PERFORMANCE Confidential & Proprietary 6 2/6/15 Immobility, decreased activity and/or impaired sensory perception interventions • Restorative & Mobility Programs – Restorative Nursing Program-MDS Requirements • Technique, training or skill practice was performed for a total of at least 15 minutes per 24 hours • The 15 minutes can be broken up (i.e. remove & clean splint and skin, inspect skin and perform ROM for a total of 5 minutes 3x/day) • Restorative nursing does not include groups with more than four residents per supervising helper or caregiver. PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Restorative & Mobility Programs – Restorative Nursing Program-MDS Requirements • The care plan & medical record must document measurable objective and interventions • The medical record must reflect periodic evaluation by a licensed nurse. • Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity • A registered nurse or licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Restorative & Mobility Programs – Assistive devices to promote mobility: • • • • • • • • • Grab Bars for repositioning & egress Bed at correct egress height Utilize electric bed to assist to a standing position Lifts (ceiling, sit to stand, transfer, walking) Lateral transfer devices Repositioning slings Walking devices (cane, walker, etc) Rocking chairs Assistive devices PEOPLE PASSION PERFORMANCE Confidential & Proprietary 7 2/6/15 Immobility, decreased activity and/or impaired sensory perception interventions • Pressure Redistribution: The ability of a support surface to evenly distribute load over the contact area of the human body. • Pressure redistribution replaces prior terminology of pressure reduction and pressure relief support surfaces – The goal of the support surface is to • Evenly distribute pressure over the surface • Envelop and immerse into the support surface • Control microclimate PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Support surfaces for the bed: – Preventative (foam, foam/air) – Low Air-loss/Alternating air – Air fluidized – Fluid Immersion Simulation • Document on care plan type and date implemented • Not a substitute for turning schedules • Heels may be especially vulnerable even on low air loss beds PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Elevation of heels OFF of the surface – Pillow prop – Wedges – Heel lift boots • Always provide heel elevation bilaterally • Feel to ensure the heel has no pressure NO YES YES NO YES PEOPLE PASSION PERFORMANCE Confidential & Proprietary 8 2/6/15 Immobility, decreased activity and/or impaired sensory perception interventions All wheelchairs should have a cushion • Air and gel is more aggressive than foam products7 • A sitting position = head elevation of 30 degrees or higher • All sitting surfaces should be evaluated for pressure redistribution PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Recommend a Therapy screen for wheelchair cushion • When positioning in a chair consider: – Postural alignment – Weight distribution – Sitting balance – Stability – Pressure redistribution PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions PEOPLE PASSION PERFORMANCE Confidential & Proprietary 9 2/6/15 Immobility, decreased activity and/or impaired sensory perception interventions PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Develop an INDIVIDUALIZED turning & repositioning schedule • Current Standard: – Turn and reposition at least every 2 hours while lying – Reposition at least hourly in a sitting position (if the resident can reposition themselves in wheelchair encourage them to do so every 15 minutes) – When possible avoid positioning on existing pressure ulcer PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions F314 Guidance in LTC, Tissue Tolerance: • Tissue tolerance is the ability of the skin and it’s supporting structures to endure the effects of pressure with out adverse effects • A skin inspection should be done, which should include an evaluation of the skin integrity and tissue tolerance, after pressure to that area, has been reduced or redistributed PEOPLE PASSION PERFORMANCE Confidential & Proprietary 10 2/6/15 Immobility, decreased activity and/or impaired sensory perception interventions • Establish an Individualized repositioning schedule based on: • Individual tolerance • Preferences (i.e., wanting uninterrupted sleep, comfort) • Characteristics of the pressure-redistribution support surface • Utilize repositioning & positioning devices as appropriate – Remember to protect your back and safely handling the resident when repositioning!!! PEOPLE PASSION PERFORMANCE Confidential & Proprietary 31 Immobility, decreased activity and/or impaired sensory perception interventions • F314: “Momentary pressure relief followed by a return to the same position is usually NOT beneficial (microshifts of 5 to 10 degrees or a 10-15 second lift).” • “Off-loading” is considered 1 full minute of pressure RELIEF • Good compromise if choosing not to reposition PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Restraints – Release restraints at designated intervals – More importantly try to eliminate restraints PEOPLE PASSION PERFORMANCE Confidential & Proprietary 11 2/6/15 Immobility, decreased activity and/or impaired sensory perception interventions • Pain management – Pre-medicate the individual 20 -30 minutes prior to repositioning, treatment or cares as appropriate – Scheduled pain medication – If palliative care is the primary goal; comfort may supersede prevention causing the individual to have a single position of comfort. – Utilize appropriate support surfaces in the bed and wheelchair to provide comfort as well as improve pressure redistribution PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Pain management – Do not place Individuals directly on a wound when ever possible or limit the time on the area – Pad and protect bony prominences (note: sheepskin, heel and elbow protectors provide comfort, and reduce shear & friction, but do NOT provide pressure reduction) – Do not massage over bony prominences PEOPLE PASSION PERFORMANCE Confidential & Proprietary Immobility, decreased activity and/or impaired sensory perception interventions • Pain Management, Continued: • • • • • • • • Provide soothing music Distraction Conversation Relaxation techniques Position changes Meditation Guided imagery Transcutaneous electrical stimulation (TENS) PEOPLE PASSION PERFORMANCE Confidential & Proprietary 12 2/6/15 Braden Scale: Moisture • Moisture can irritate and breakdown the skin – Incontinence of bladder – Incontinence of bowel – Excessive perspiration – Moisture within skin folds PEOPLE PASSION PERFORMANCE Confidential & Proprietary Moisture • Interventions to protect the skin from moisture • • • • Individualized B & B Program Peri-care after each episode of incontinence Appropriate, dignified absorptive incontinent products Apply a protective skin barrier to peri-area or wound edges (ensure skin is clean before application & appropriate with the absorptive product) • Foley catheter and/or fecal tubes/pouches as appropriate (in LTC for stage III or IV only) PEOPLE PASSION PERFORMANCE Confidential & Proprietary Moisture • Interventions to protect the skin from moisture – 4x4’s, pillow cases or dry cloths in between skin folds – Inter Dry Ag sheets if prone to intertrigo infections – Antifungal powder or ointment for active intertrigo infections – Bathe with MILD soap, rinse and gently dry – Keep linen dry & wrinkle free PEOPLE PASSION PERFORMANCE Confidential & Proprietary 13 2/6/15 Moisture • If there is already an elimination problem on the care plan that addresses the interventions: – List “incontinence of bowel and/or bladder” as a risk factor under skin integrity, however, – State under interventions: ü See elimination problem PEOPLE PASSION PERFORMANCE Confidential & Proprietary Braden Scale: Nutrition • Nutritionally at Risk – Serum Albumin below 3.5g/dl – Pre-Albumin 17 or below (more definitive than an albumin level) – Significant unintended weight loss – Very low or very high body mass index – Inability to feed self – Poor appetite – Difficulty swallowing – Tube fed – Admitted with or history of dehydration PEOPLE PASSION PERFORMANCE Confidential & Proprietary Nutrition Interventions for Nutritional deficits • Dietary consult to determine interventions – Provide protein intake of 1.25-1.5 gm/kg/body weight daily7 – 30-35 kcalories/kg of body weight/day7 PEOPLE PASSION PERFORMANCE Confidential & Proprietary 14 2/6/15 Nutrition Interventions for Nutritional deficits • Dietary consult to determine interventions – Provide a simple multivitamin5 – Unless a resident has a specific vitamin or mineral deficiency, supplementation with additional vitamins (i.e., Vit. C) or minerals (i.e., zinc) may not be indicated5 • Zinc no more than 40mg/day for no more than 2-3 weeks5. • Higher dosages or long term use of zinc can decrease copper status and lead to anemia5 – Appetite stimulants as appropriate PEOPLE PASSION PERFORMANCE Confidential & Proprietary Nutrition Interventions for Nutritional deficits – Providing food per individual preferences – Provide adequate hydration – Accurate Intake, output and weights PEOPLE PASSION PERFORMANCE Confidential & Proprietary Nutrition • If nutrition is already addressed on the care plan: – List “nutritionally at risk” as a risk factor under skin integrity, however, – State under interventions: ü See nutritional problem PEOPLE PASSION PERFORMANCE Confidential & Proprietary 15 2/6/15 Braden Scale – Friction & Shear • At risk for friction and shear • Needs assistance with mobility • Tremors or spasticity • Slides down in the: • Bed • Wheelchair/sitting surface • Agitation PEOPLE PASSION PERFORMANCE Confidential & Proprietary Friction and Shear • Interventions for Friction and Shear – Lift -- do not drag -- individuals – Utilize lifting devices & slings • Ceiling liFs • Transfer liFs • Sit to stand liFs • Walking liFs • Lateral transfer devices • Specialty slings • Reposi.oning slings • Limb liFer slings PEOPLE PASSION PERFORMANCE Confidential & Proprietary Friction and Shear • Interventions for Friction and Shear – Elbow or heel pads – Protective clothing – Protective dressings or skin sealants – Raise the foot of the bed before elevating – Wedge wheelchair cushions (therapy referral) – Pillows PEOPLE PASSION PERFORMANCE Confidential & Proprietary 16 2/6/15 Comprehensive Skin Integrity Risk Assessment • In addition to the Braden Scale, review – – – – – – – – – H&P Diagnosis Physician/NP notes Consultations (podiatry, wound clinic, etc.) Medications Labs (albumin and pre-albumin) Blood sugars MDS/CAAs (if complete) Interview resident & family, etc. PEOPLE PASSION PERFORMANCE Confidential &IProprietary Footer nfo Here 49 Other Risk Factors not on the Braden Overall diagnoses that can lead to skin breakdown: • Anything that impairs blood supply or oxygenation to the skin (cardiovascular or respiratory disease) • Immunosuppression • History of pressure ulcers and skin breakdown – indicate type of skin breakdown, location and stage (pressure ulcer) if known • End stage diseases (renal, liver, heart, cancer) PEOPLE PASSION PERFORMANCE Confidential & Proprietary Other Risk Factors not on the Braden Overall diagnoses that can lead to skin breakdown: • Diabetes – blood sugars consistently above 140 or A1c greater than 7 • Anything that renders the individual immobile • Anything that can affect his/her nutritional status (inability to feed themselves) • Anything that affects his/her cognition PEOPLE PASSION PERFORMANCE Confidential & Proprietary 17 2/6/15 Other Risk Factors not on the Braden Medications or Treatments, such as: • • • • • Steroid therapy Medications that decrease cognitive status Renal dialysis Head of bed elevation the majority of the day Medical Devices (tubes, casts, braces, shoes, positioning devices) PEOPLE PASSION PERFORMANCE Confidential & Proprietary Other Risk Factors not on the Braden • Other Risk Factors – Fragile skin or dry cracked skin – Choosing not to follow interventions – be specific as to what they are not following – Pain – Smoking PEOPLE PASSION PERFORMANCE Confidential & Proprietary 53 Overall Prevention Interventions • Monitor skin – this should be listed on all plans of care • Inspect skin daily by caregivers • Inspect bony prominences look & feel • After pressure has been reduced/redistributed • Under medical devices (cast, tubes, orthoses, braces, etc). • Weekly head to toe skin inspection by a licensed nurse PEOPLE PASSION PERFORMANCE Confidential & Proprietary 18 2/6/15 Overall Prevention Interventions • If the resident has a wound it should be assessed/documented by a licensed nurse at least every 7 days PEOPLE PASSION PERFORMANCE Confidential &IProprietary Footer nfo Here 55 Interventions • Medications or Treatments – – – – Evaluate steroid use and dosage Adjust medications as appropriate to improve cognitive status Notify dialysis of skin concerns and interventions Keep head of bed at the lowest level possible & ensure appropriate support surface – Pad medical devices and ensure proper fit PEOPLE PASSION PERFORMANCE Confidential & Proprietary Interventions • Smoking – Risk discussion – Smoking cessation plan if resident agrees PEOPLE PASSION PERFORMANCE Confidential & Proprietary 19 2/6/15 Interventions • Consultation – Provide adequate Psychosocial support/Psychology referral – Obtain a Podiatrist, Dermatologist, Vascular Physician and/or Wound Care Consultation as appropriate – Involve primary physician and/or appropriate physician support PEOPLE PASSION PERFORMANCE Confidential & Proprietary Interventions • Diabetes – Monitoring & management of diabetes as ordered – Dietary consultation – Exercise program/therapy – Diabetic foot care • Can state “see diabetes problem” PEOPLE PASSION PERFORMANCE Confidential & Proprietary Interventions • Dry or Fragile Skin – Apply non irritating lotion at least daily – Protective clothing PEOPLE PASSION PERFORMANCE Confidential & Proprietary 20 2/6/15 Other Risk Factors not on the Braden • Lower extremity disease – Arterial insufficiency – Venous insufficiency – Peripheral neuropathy – Diabetic ulcers PEOPLE PASSION PERFORMANCE Confidential &IProprietary Footer nfo Here 61 Interventions • Lower Extremity Disease – Etiology identification is imperative!!!! • Ankle Brachial Index (ABI) • Vascular/Physician consultation for diagnosis and plan • Goal is to identify the disease process to prevent or minimize skin breakdown PEOPLE PASSION PERFORMANCE Confidential & Proprietary Lower Extremity Disease • • • • • • • Appropriate, well fitting foot wear at all times Inspection of feet Appropriate nail and foot care No warm foot soaks Keep clean and dry Exercise Venous Insufficiency – Leg elevation – Compression therapy PEOPLE PASSION PERFORMANCE Confidential &IProprietary Footer nfo Here 63 21 2/6/15 Interventions • Dermatitis and other skin concerns – Dermatology Consultation – Appropriate treatment for etiology of skin concern PEOPLE PASSION PERFORMANCE Confidential & Proprietary Interventions Individual choice • Be specific as to what the individual is choosing not to do or allow – List interventions and alternatives tried on the plan of care (do not delete) – Document date and location of risk/benefit discussion on care plan – Re-evaluate at care planning intervals PEOPLE PASSION PERFORMANCE Confidential & Proprietary Care Plan • Care Plan Tips – Ensure care plan has appropriate goals – Only list the type of ulcer and location of it on the care plan (i.e., Pressure ulcer to right trochanter) – Once the pressure ulcer heals, ensure it gets listed on the care plan (i.e., history of pressure ulcer to right trochanter) – Physician diagnosis and prognosis are appropriate PEOPLE PASSION PERFORMANCE Confidential & Proprietary 22 2/6/15 Communication • Nursing Assistant assignment sheets should include: – – – – – – – – – Turning & Repositioning schedule Type of Bed & Wheelchair surface Bowel & Bladder program and products Type of heel lift Restorative cares Supplements to be given Skin protection devices/lotion Lifting/transferring instructions & equipment/devices Dressing(s) and the location, to notify the nurse if missing, loose or soiled – Inspect skin daily – Notify nurse of any skin concerns PEOPLE PASSION PERFORMANCE Confidential & Proprietary Case Study Ima Swee/e • 75yo female • Suffered from a stroke affec.ng her right side. • Progressed to the point where she can use a walker, independently for short distances. • Suffers from depression and does not like to leave her room. • Is intermiDently incon.nent and requires pad changes qshiF. However, she does not inform staff/family when she has been incon.nent. PEOPLE PASSION PERFORMANCE Confidential & Proprietary Case Study Ima Sweetie • Prefers to spend most of her day laying in her bed on right side, despite attempts to reposition q2 hrs. • States she has diminished sensation on her entire right side • She occasionally slides down in her chair at the evening meal • Eats about half of each meal served, and occasionally will take dietary supplements • She has fragile skin & states she has had many skin tears on her hands and arms • Her right hand is starting to contract PEOPLE PASSION PERFORMANCE Confidential & Proprietary 23 2/6/15 Resources Available Resources and Web Sites: – www.wocn.org (Wound, Ostomy & Continence Nurse Society) – www.ahrq.gov (Agency for Health Care Research and Quality) – www.abwmcertified.org (American Board of Wound Management) – www.npuap.org (National Pressure Ulcer Advisory Panel) – www.woundsource.com (Great source to find wound care products) – www.wcei.net (Wound care Education Institute) PEOPLE PASSION PERFORMANCE Confidential & Proprietary References 1. Bergstrom, N., Horn, S.D., Rapp, M.P., Stern, A., Barrett, R., Watkiss, M. (2013). “Turning for ulcer reduction: a Multisite randomized clinical trial in nursing homes.” The American Geriatrics Society 61:1705-1713 2. Defloor, T., D. De Bacquer, M.H.F. Grypdonck. (2005). “The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers.” International Journal of Nursing Studies 42(1):37-46 3. Eyers, I., Young, E., Luff, R., Arber, S. (2012) “Striking the balance: night care versus the facilitation of good sleep.” British Journal of Nursing 21(5). 303-307 4. Kamel, N., Gammack, J. (2006) “Insomnia and the elderly: cause, approach, and treatment.” American Journal of Medicine 119, 463-469 5. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: Clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009 6. Sanford, J.T., Townsend-Roccichelli, J., VandeWaa, E. (2010) “Managing sleep disorders in the elderly.” The Nurse Practitioner: The American Journal of Primary Care Vol 35:5 PEOPLE PASSION PERFORMANCE Confidential & Proprietary References 7. Wound Ostomy and Continence Nurses Society. (2010). Guideline for Prevention and Management of Pressure Ulcers. Mount Laurel, NJ: Wound, Ostomy, and Continence Nurses Society 8. Wound Ostomy and Continence Nurses Society. (2008). Guideline for Management of Wounds in Patients with Lower-Extremity Arterial Disease. Mount Laurel, NJ: Wound, Ostomy, and Continence Nurses Society 9. Wound Ostomy and Continence Nurses Society. (2012). Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Glenview, IL: Wound, Ostomy, and Continence Nurses Society 10. Wound Ostomy and Continence Nurses Society. (2011). Guideline of Wounds in Patients with Lower-Extremity Venous Disease. Glenview, IL: Wound, Ostomy, and Continence Nurses Society PEOPLE PASSION PERFORMANCE Confidential & Proprietary 24 2/6/15 QUESTIONS Thanks for your participation!!! Jeri Lundgren, RN, BSN, PHN, CWS, CWCN Vice President, Clinical Consulting jeri.lundgren@joerns.com Cell: 612-805-9703 PEOPLE PASSION PERFORMANCE Confidential & Proprietary 25
