Pressure Ulcer Prevention
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BWAT-BASED TREATMENT GUIDELINES
A resident's total BWAT score can be categorized as one of four "severity states" to guide care planning. Presented below, these severity states and their associated treatment goals are presented as a generic guideline for developing treatment plans. It should be noted, however, that clinicians ultimately remain responsible for individualizing each resident's care plan.
- BWAT Minimal Severity Scores 13-20
Pressure sores with a PSST total score of 13 -20 are generally stage I lesions with intact skin at high risk for altered integrity or shallow stage II, partial thickness pressure sores. The main goals for wounds in this severity state are to prevent further damage and to provide a moist wound environment for healing.
- BWAT Mild Severity Scores 21-30
Pressure sores with mild severity include both partial thickness wounds and full thickness wounds. The goals of care for partial thickness wounds with mild severity scores are to absorb excess wound exudate, maintain a clean wound bed, and maintain a moist environment.
Full thickness wounds with mild severity scores offer more options for treatment as the wound can present as a clean full thickness wound or as a wound filled with necrotic debris. The goals of care for full thickness wounds with mild severity scores are to obtain or maintain a clean wound bed, provide a moist environment, absorb excess exudate, prevent premature closure, and reduce wound dead space. Wounds with mild (and moderate) severity scores have the most clinically diverse presentations and so choices regarding treatment are numerous.
- BWAT Moderate Severity Scores 31-40
Wounds in this severity state are predominantly full thickness stage III or IV pressure sores. Goals of care are to obtain or maintain a clean wound bed, absorb excess exudate, eliminate dead space to prevent premature wound closure, and provide a moist wound environment.
- BWAT Severity Scores 41-65
Wounds with BWAT total scores in this range are generally stage III or IV full thickness pressure sores with more severe clinical manifestations, including undermining and necrosis. The generic treatment plan for these wounds is some method of debridement. The goals of care are to identify and treat infection, obtain or maintain a clean wound bed, absorb excess exudate, eliminate dead space to prevent premature wound closure, and provide a moist wound environment.
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