MULTIDISCIPLINE CARE PLAN - MCP
STAGE 3-4 PRESSURE ULCER
Stage 3:  Full thickness skin loss involving damage to or necrosis of SQ tissue that may exten down to, but not through, underlying fascia.   (Presents as a deep crater with or without undermining adjacent tissue).   Stage 4:  Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures.  (Undermining and sinus tracts also may be present.)

DATE

PROBLEM OR NEED

MEMBER GOAL

STAFF APPROACHES/INTERVENTIONS

RESPONSIBLE
DISCIPLINE
  Impaired skin integrity
Stage ___ ulcer location:
__________________
__________________
__________________		 Ulcer will progress towards reduction in size, 
free of necrotic tissue, and closure
by: ______________________

 

 1.  Use and follow also skin care protocol Braden score 16 or less.  (Preventive
meausures

 

 

  
      2.  Assess pressure ulcer by using wound assessment from weekly or if
significant change.		  
      3. Avoid positioning patient on the pressure ulcer.  
      4.  Avoid massage over bony prominence.  
      5.  Patient should consume 75% of the meals from the basic Four Food Groups.  
      6.  Do calorie count for 3 days.  
      7.  Provide 1/2 cup orange juice or similar high vitamin C souce TID.  
      8.  Provide 6 oz high protein supplement TID.  
      9.  Consult with physician about consideration of multivitamin/mineral supplement.  
      10. Air bed is recommended for patients with multi-truncal Stage 3 or 4 ulcers
aand those who have failed to heal on another type of mattress.		  
      11. Prevent pain related to pressure ulcer or its treatment.  
      12. Provide analgesic as needed.  
      13. Cleanse wound initially and at each dressing change with Normal saline or
non-cytotoxic wound cleanser.  Ensure complete ulcer cleaning.		  
      14.  DO NOT clean ulcers with skin cleansers or anti-septic agents such as
Betadine, lodophor, sodium hypochlorite, Hydrogen peroxide, or acetic acid.		  
      15. Select appropriate method of debridement if indicated (See P&P #7
Debridement).  Discontinue debridement when ulcer is clean.		  
      16. Select and apply appropriate dressing based on assessment -
(hydrocolloids, hydrogels, alginates, foam dressings, guaze).		  
      17.  Choose a dressing that keeps the periulcer skin dry while keeping the ulcer bed moist.  
      18. Change dressing when strike through is apparent regarding of time frame.  
      19.  Loosely fill all wound cavities with dressing material. DO NOT pack wound tightly.  
      20. For Stage 3 only:  consider a trial of topical antibiotics (silver sulfadizaine 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).		  
      21.  Re-evaluate effectiveness of treatment plan every two weeks.  
      22. Provide patient education materials as needed.  
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