MULTIDISCIPLINE CARE PLAN - MCP
STAGE 2 PRESSURE ULCER

DATE

PROBLEM OR NEED

MEMBERS GOAL

STAFF APPROACHES/IMPLEMENTATION

RESPONSIBLE
DISCIPLINE

  Impaired skin integrity   
Stage 2 ulcer location:
Ulcer will progress towards reduction in size 
and closure by: _____________________
1.  Use & follow also skin care protocol Braden Score 16 or less
(preventative measures).
 
      2.  Assess pressure ulcer by using wound assessment form
weekly or if significant change.
 
      3.  Avoid positioning patient on the pressure ulcer.  
      4.  Do not massage pressure area or bony prominence.  
  (Partial thickness skin loss
involving epidermis, dermis
or both.  Ulcer is superficial
and presents clinically as
an abrasion, blister or
shallow crater.
  5.  Patient should consume 75% of the meals from the basic Four
Food Groups.

 

 

 
      6.  Include 1/2 cup orange juice daily BID or similar high vitamin source.  
      7.  Include 6 ox high protein supplement daily.  
      8.  Consult with physician about consideration of multivitamin/mineral
supplement.
 
      9.  Prevent pain related to pressure ulcer or its treatment.  
      10. Provide analgesic as needed.  
      11. Cleanse wound initially and at each dressing change using NS or
non-cytotoxic wound cleanser.
 
      12. DO NOT clean ulers with skin cleansers or antiseptic agents such as
Betadine, lodophor, sodium hypochlorite, hydrogen peroxide, or
acetic acid.
 
      13. Select and apply appropriate dressing:  apply transparent film, foam,
hydrocolloid or hydrogel dressing, change every 3-7 days and prn.
 
      14. Choose a dressing that keeps the periulcer skin dry while keeping
the ulcer bed moist.
 
      15. Re-evaluate effectiveness of treatment plan every two weeks.  
      16. Consider a trial of topical antibiotics (silver sulfadizine or triple
antibiotic ointment) for clean pressure ulcers that are not healing
or are continuing to produce exudate after 2-4 weeks of optimal
patient care (need doctor order for this).
 
      17. Provide patient education materials as indicated.  
1.  Nursing
Signatures:
2.  Physical Therapy 3.  Dietary 4.  Activities 5.  Social Services 6.  Spiritual 7.  Member
1. __________ 2. _______________ 3. ____________ 4. ____________ 5. ______________ 6. ______________ 7. ___________
1. __________ 2. _______________ 3. ____________ 4. ____________ 5. ______________ 6. ______________ 7. ___________
MEMBERS NAME: ______________________________ DATE: ________ REVIEW DATE: _________________ R#___________

ACWCP - 1998