text:
Full Face Label
DVD Label template
How to Print DVD Labels
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Ever since CDs/DVDs became popular, it was everyone's first wish to put a tag on their favorite discs. However, doing this was quite a tedious process. People used pens and markers which would ruin the look of the disc or they would use a piece of paper to write the DVD title, but if the paper was too thick it would not go into the DVD tray or worse, become jammed inside it causing further damage. Moreover, if you ordered a special label according to your preferences, it would be too expensive and you would have to wait for it up to a few days. But this are no problems anymore with the custom DVD label template!
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- Download the CD/DVD label maker software for free to try it on your computer.
- Install the DVD label making software on your computer and select the "yes or run" option when it asks you to install the software on the hard drive in your computer.
- Start with standard of fullface label template and edit the design according to your preference.
- Once you are done editing and are satisfied with the result, click on 'Print'!
- Get the print-out and put it on your disc with the help of the disc labeler to see how it looks! {For the record, the dimension of a Full Face CD Label without bleeding area should be 4.64 inches (118 mm) in diameter}
The RonyaSoft CD/DVD Labeler can be used to make and print not only DVD labels, but also CD case inserts, DVD box covers, Blu-Ray covers, paper CD sleeves and origami CDs. With this CD DVD label printing software, you will be able to create unique and art nouveau designs inspiring your friends to try it too! The complete label design software includes label templates as well as CD/DVD box set labels and fun clipart images to use on the CD DVD label.
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Disc labeling software supports a wide range of disc labels, including: Ace 30700 series, Avery 5691, Avery J8676, Boma LS101, CoolBeLa LS101HIG, Herma, Kyso 5511 CD , Lorenz Bell LB6681, Neato Full Coverage CD 2-up, Printec AnyLabel L3771 L3773, Sanwa LB-CDR001 CD, Zweckform L6044, Zweckform L6047 and similar.


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Coleman Milwaukee Brewers Quad Chair With Cooler
Product Information:
You won't miss a second of the action because you'll never have to leave your seat with the Coleman® Milwaukee Brewers Cooler Fold-Out Chair. This chair allows you to have everything by your side with the built-in four to six can soft cooler, program pouch, and cup holder. In addition to supreme convenience, this chair features Brewers logos on the front and back, so you can show off your team pride all season long.
- Coleman® Milwaukee Brewers Quad Cooler Chair
- Team logo printed on front and back of seat
- Carrying bag is team colored and features logo
- Standard-size cup holder in right armrest
- 17.5 mm powder coated steel frame for durability
- Cooler portion with 4-6 can capacity
- Maximum weight capacity is 300 lbs.
- Seating area measures 29" x 21" x 34"
- Officially licensed by MLB®
- Coleman
Country of Origin: BulgariaWeb ID: 24875556

subset: commoncrawl


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Can't afford the new law
March 2, 2014
Craig Smith, Garrison As a North Dakota small business owner, I have a great deal of concern about the new Health Insurance Tax that was buried within the pages of the Affordable Care Act, institute......
gosh, just look at all the racists that are complaining about a 'little' increase in premiums...mine 'only' would be going up 300+%. and i would now get to help finance abortions ! what a country.
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Someone should tell hannity u can work in a safer Minn. for less money because u won't pay $3,000 per mo. 4 rent. ND Oil can kill u, after it pollutes u.
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B4 the ACA, a farmer said on talk radio he was quoted $25,000 per month for he and his wife, 4 health ins.
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There is something worse than the ACA. That would b letting medical care, oil and big banks control our lives 1 iota more than they do now. The fixed price of gasoline and diesel says all they need 2 say. The high cost of medical care is all they need 2 say. I believe we rate 37th in the world for healthcare. The collapse of 2008 is all we need to know about the big banks.
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MRC: i did not say that. My point is the Minn. case proves u can raise taxes to solve budget problems without crushing your economy. The current republican policy in the Fed is no new taxes because they say it will damage the economy.
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@muleskinner I agree that there should be a more fair approach based on the earnings but it should also take into account the number of employees. For example, WhatsApp has 35 employees and a revenue of ~$254 million. Spending $725,000 per employee would be very rediculous.
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It is the stupidest law ever passed by a legislative body organized by mankind.
If the law stated that all health care costs must be financed by income, a percentage of that income, then it might be a fair law.
The mandate should state that 10 percent of one's income must be used for health care costs. A lower limit would exclude anyone with less than 100,000 dollars in income. If your income is 100,001 dollars, your healt care mandated cost would be 10 cents.
If you make 50 million dollars per year, your health care mandated cost would be 5 million dollars.
About the only fair way to make it work, otherwise, it is doomed because it is one stupid law.
As it is, the law is just plain stupid.
Can't expect anything else from a Congress that is replete with idiots.
Stupid is as Stupid does.
Forrest Gump would agree.
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Hmmmm isn't it peculiar that none of that would affect Mr. Smith's business? Google shows that he owns a liquor shop called Live Well with around 4 employees.
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This site was full of calculations and for what is now considered deductible expenses concerning employee health insurance, etc.
At least others have read the bill to see what's in it...
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More from obamacarefacts...
"The ObamaCare employer mandate/employer penalty, originally set to begin in 2014, will be delayed until 2015/2016.
"The ObamaCare "employer mandate" is a requirement that all businesses with over 50 full-time equivalent (FTE) employees provide health insurance for their full-time employees, or pay a per month "Employer Shared Responsibility Payment" on their federal tax return.
"Employer mandate update: Small businesses with 50-99 full-time equivalent employees will need to start insuring workers by 2016. Those with a 100 or more will need to start providing health benefits in 2015. Health care tax credits have been retroactively available to small businesses with 25 or less full-time equivalent employees since 2010."
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obamacarefacts . com/obamacare-employer-mandate
"The annual employer mandate fee (officially called an Employer Shared Responsibility Payment) is a per employee fee for employers with over 50 full-time equivalent employees who don't offer health coverage to full-time employees.
"The employer mandate is based on full-time equivalent employees, not just full-time employees.
"The fee is based on whether or not you offer affordable health insurance to your employees that provides minimum value (explained below).
"The annual fee is $2,000 per employee if insurance isn't offered (the first 30 full-time employees are exempt)."
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Six of one, half-dozen of another.
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WA Times 2-5-14
President Obama's health care law will push 7 million people out of their job-based insurance coverage — nearly twice the previous estimate, according to the latest estimates from the Congressional Budget Office released Tuesday.
CBO said that this year's tax cuts have changed the incentives for businesses and made it less attractive to pay for insurance, meaning fewer will decide to do so. Instead, they'll choose to pay a penalty to the government, totaling $13 billion in higher fees over the next decade.
But the non-partisan agency also expects fewer people to have to pay individual penalties to the IRS than it earlier projects, because of a better method for calculating incomes that found more people will be exempt.
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Legand: how does raising taxes on people create jobs...besides in government? How does raising taxes lead to the creation of more goods and services that people actually want to buy?
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15,000 spouses of UPS workers were dropped from health insurance coverage in August of 2013.
Google 1099 jobs and the Obamacare effect on those 1099 jobs.
It's not rocket science, people cannot afford Obamacare.
Thems the facts, Jack.
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Great comments BG. It is noteworthy that koch's and roger ailes r concentrated on Obama (who is not running)and thereby ignoring their competition. That goldmark guy did the same thing in ND. i am not afraid to give them that tidbit because i don't think they read. They only exist from lies. Rand Paul said "misinformation works". They labeled Biden a babbling idiot even though he has never said anything as stupid as most of the t party every time they speak. Rick and sarah r better ads then the dems pay 4.
4 Agrees | 2 Disagrees | Report Abuse »
MR: Your comment would suggest the job loss after 2008 was a mere nuisance and deficits a passing fad. The success in Minn. is what economists dream of. Oh i forgot; the collapse was all on Obama. I have said 4 my entire life "i would sooner have a job and pay taxes than have no job".
5 Agrees | 2 Disagrees | Report Abuse »
Anybody know what "tax" or "fee" this letter writer is talking about? I heard of a one time surcharge on policies, but it ain't $500, more like $60.
Pass the cost on to the customer, we always pay anyhow.
4 Agrees | 1 Disagrees | Report Abuse »
You keep repeating the same old crepe but never do you produce a link to a credible source. You are just making things up aren't you?
5 Agrees | 3 Disagrees | Report Abuse »
Where are you getting this 6 MILLION people dropped? You yourself said 4.2 million had re signed up for Obamacare. You sound like a sprinkler stuck on stupid.
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since Legend likes to discuss other states maybe he can explain the anomoly in WI. Oh, and MN started to make corrections with their financial disaster when they elected a republican controlled legislature. And they didn't raise taxes. In fact property taxes have dropped quite a bit there also.
3 Agrees | 4 Disagrees | Report Abuse »
Does anyone know that government healthcare, Medicare, DOES have pre-existing conditions attached to it? I thought government was forword-looking enough to have eliminated that clause...especially when Omamacare came along....
3 Agrees | 5 Disagrees | Report Abuse »
There seems to be nobody in Minnesota who thinks that these taxes were a good idea. Do a Google search on the matter. I dare you.
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Legend: your "left wing economics" has done nothing but burdened real people and made them angry. How do you expect to keep "your" people in office when they keep intentionally doing things to anger the masses? You keep acting opposite your self interests!
4 Agrees | 3 Disagrees | Report Abuse »
"Check out Minnesota 4 proof of left wing economics. They have recovered all of their 2008 job loss. They did the opposite of what our national republican party says is the answer. They raised taxes and now have a great surplus"
Hey Legend, if you're going to post something about Minnesota, you'd better check your facts before posting it in a forum read by someone who actually lives there.
Did you know that, despite the much vaunted surplus, there's a very real chance that many of those taxes are going to be rolled back in the coming legislative session? You know why? They (meaning the state and those running it) might have gotten their short-term score, but they've also found a number of negative, unintended, and unanticipated (except for those outside of their echo chamber) problems with the taxes. Example: their business-to-business warehouse tax has encountered such widespread opposition that repleaing it is almost necessary if they (those running the state) want re
2 Agrees | 3 Disagrees | Report Abuse »
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Title: Pikmin 3
Price: $59.99
System(s): Wii U
Release Date: August 4, 2013
Publisher (Developer): Nintendo (Nintendo and Monolith Soft)
ESRB Rating: "Everyone 10+" for Cartoon Violence
Pikmin has always been considered an iconic Nintendo series, despite the fact that there have only been 3 installments in 12 years. When Pikmin 3 was announced as a Wii U launch title, it was an exciting moment. Not only was the series going to be resurrected 9 years after Pikmin 2, but it would be among the first next gen Nintendo games.
Unfortunately, there were some delays, which lead to Pikmin 3 missing the launch window. Despite it all, the game was absolutely worth the wait. While it isn't perfect, it's just what Wii U owners need.
Koppai needs fruit!
The Koppaites are in trouble. The planet of Koppai experienced a massive population boom, and is in dire need of food supplies to support the people and prevent mass starvation. Exploratory SPEROS were sent out and one planet was found with viable foodstuffs – PNF-404.
A crew of three was sent out on the S. S. Drake. Their goal was to explore PNF-404, searching for as much food as possible to retrieve seeds for Koppai. Except there was a problem. As the ship entered the planet's orbit, there was a malfunction that separated the crew and caused the Cosmic Drive Key to disappear onto the planet.
Pikmin 3 begins with players controlling Alph, the S. S. Drake's engineer, as he attempts to find his companions, enough fruit to make juice to survive, fruit seeds to save Koppai, and the Cosmic Drive Key needed to get home.
Recruit some Pikmin, find some fruit, and beat some baddies.
Pikmin 3 is a real time, strategic adventure. Players control the three Koppaite characters, Captain Charlie, Botanist Brittany, and Engineer Alph, as they use Pikmin to traverse PNF-404 in the search of fruit and the Cosmic Drive Key. Players use each character's whistle to round up Pikmin, and can then throw the colorful characters at items, fruit, or defeated monsters to take them back to the S. S. Drake or Pikmin's Onion. Pikmin can also be charged with destroying obstacles, creating bridges, defeating enemies, and other tasks to safely proceed through the world.
The thing is, you don't have all the time in the world to accomplish tasks in Pikmin 3, and you must make sure you have the right Pikmin for the job. Players get about 15 minutes on PNF-404, before they have to return to the ship for the night. Food's running low, so enough juice must be found each day to keep playing. On top of that, certain tasks need certain Pikmin. Only yellow Pikmin can work with electricity. Red are fire resistant and better fighters. Rock Pikmin are needed to shatter glass and crystal. Blue Pikmin can swim. Flying Pikmin are best for item retrieval.
Just be aware that Pikmin 3 can be stressful. The deadline, the constant search for food to keep Alph, Brittany and Charlie alive, the switching between characters, and some of the boss fights made my heart race. I never felt this kind of pressure in Pikmin or Pikmin 2, and it left me twitching like Tweak from South Park. A little challenge and pressure isn't bad, but in the beginning of the game, I constantly felt this weight on my shoulders and it hampered my enjoyment of the game. Once you know where fruit is in areas, the anxiety is alleviated, but I would have liked a little more of a safety cushion so I didn't feel so rushed. Granted, Pikmin 3 does eliminate Pikmin and Pikmin 2's stricter time limits, so that is a blessing. Just within the first two hours of play, I felt overly consumed by the quest for fruit.
After that initial, harrowing few hours, Pikmin 3's only flaw appears. The control scheme isn't that good. I began by trying to only use the Wii U GamePad, but the throwing mechanic is lacking if you only use the tablet. It's hard to aim precisely. Using the Wii remote and nunchuk is much more natural and accurate, but then you have to have the tablet nearby, perhaps in a lap, for checking maps, supplemental texts or occasional communication between characters.
These control issues are even more of a hinderance in the supplemental Challenge and Bingo modes. Both are additional gameplay modes designed to offer additional experiences, with Challenge allowing one or two players to attempt to reach certain goals within a certain amount of time, and Bingo seeing which player(s) is better at direct Pikmin. In each case, accuracy is key. Sloppiness can cost you precious time or lose an item needed to complete a bingo grid. In each mode, the person with the remote and nunchuk will have the advantage. Both multiplayer modes are also only available for local co-op, and while that's fine for Bingo mode, I think it's a missed opportunity for the Challenge missions.
Still, aside from controls possibly making the Challenge and Bingo modes a little more difficult, both are fun little additions to the overall Pikmin 3 package. I preferred Bingo mode myself, as it was fun to attempt to gather all of the right items before my opponent, while also making a nuisance of myself to assure my victory. However, I'm confident Challenge will test those who enjoy edge of your seat, can I manage to accomplish this goal, missions.
Pick Pikmin 3
Pikmin 3 does have some minor control issues and online multiplayer support would have been nice, but it's still an incredibly solid Wii U game. In fact, I would say it is definitely a good reason to pick up a Wii U. Pikmin 3 is a lovely game, with adorable characters that belies its difficulty level. The campaigns' missions are broken up into perfectly sized bites, meaning someone could consume the entire game at once, drinking in its delightful story, or savor it over the course of a few weeks or months. Not to mention the Challenge and Bingo modes provide incentive to invite a friend over for some fun. Pikmin 3 is a must-own Wii U game, and I hope more follow.
Product Page Amazon


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text:
Paul Rozmus
I always think the hardest thing for anyone to do is to write about himself. The idea was to keep it very personal, just like the label that I started 10 years ago and by wanting to keep it on a personal basis, I named it "Face 2 Face Records".
I was born in Poland into a family where I got a lot of warmth and love when I was a child. This is what I think made me very sensitive to everything what is around me. That sensitivity with musical talent, that I inherited from my father and my musical family, helped me become a creative artist.
When I was five years old I started playing piano. I graduated from the Polish Conservatory of Music in Katowice with a Master's Degree as a composer, producer and arranger of pop and jazz music. -Doesn't it sound great? :-).
During my high school years, I was exposed to jazz and had a chance to work with the best Polish jazz players. That gave me the fundamentals of that style of music and paved the way of who I am right now as an artist. I am still very close to Pop/Rock/R&B music, but jazz influences are always recognizable in my writing, arranging and producing. The year before I immigrated to the United States, I was recognized as a conductor and songwriter in a Polish Song Festival in Opole conducting my own Big Band and getting the top award for one of my songs.
I immigrated with my family - a two year old daughter, my grandma and my wife Renata to the US. That was one of the biggest and most difficult tasks of my life. After a few years that would describe a lot of ... (well that's a story for one good book!), my family and I settled in Florida. I opened my small label Face 2 Face Records and started recording and writing again. I did release a couple of albums of my own, with the latest one (featuring Freddie Jackson, Jeff Kashiwa, Renata, and Erick Essix) getting to the Billboard Jazz charts (nr 5 :)). That CD "On The Funky Side" was also one of the most played CDs in 2002 on the Smooth Jazz Radio.
I didn't stop only on my stuff, I always loved to co-write with other musicians. Often Co-operation brings unexpected results. :) I continue a relationship with Poland. Natalia Kukulska (one of the top Polish singers) adopted two of my songs to her gold and platinum albums, and as you can see on the "Face 2 Face" webpage, there are other musicians who sing and work with me.
Listen to samples of their work and don't forget that a real musician is always proud of his/her work. The sacrifices that we (true artists of any genres) all make, are always much greater that any pay most of us will ever see... so your kindness and appreciation to art is the air that we're breathing every day...
Love you all,
Paul Rozmus


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North English, Iowa Golf Courses
Click on any the golf course listings below to explore golf courses in North English, Iowa. Find course information, driving directions, scorecards and North English, Iowa golf instructors.
Home » Golf Courses » Iowa » North English, Iowa Golf Courses
PGA of America Championships
Harbor Shores
Benton Harbor, Mich.
Sahalee Country Club
Sammamish, Wash.
Baltusrol Golf Club
Springfield, N.J.
Hazeltine National Golf Club
Chaska, Minn.


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"Pressure ulcer prevention and treatment protocol. Health care protocol." has been saved, and will be accessible from the My NGC page.
Go to My NGC
Alert me when this guideline summary is updated.
This is the current release of the guideline.
This guideline updates a previous version: Institute for Clinical Systems Improvement (ICSI). Pressure ulcer prevention and treatment. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Apr. 69 p. [102 references]
Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.
Pressure ulcers
All patients within an acute health care facility and ambulatory settings with or at risk for pressure ulcers
Note: While this protocol does not specifically address other settings, its use by them is not limited.
Evaluation/Prevention/Risk Assessment
A literature search of clinical trials, meta-analyses, systematic reviews, or regulatory statements and other professional order sets and protocols is performed.
A consistent and defined process is used for literature search and review for the development and revision of Institute for Clinical Systems Improvement (ICSI) Protocols. Literature search terms for the current revision of this document include device-related pressure ulcers in pediatric patients, occipital pressure ulcers in pediatric patients, pressure ulcer prevention, pressure ulcer prevention with devices, biofilm, hyperglycemia and pressure ulcers, deep tissue injury and stageable pressure ulcers from January 2010 through July 2011.
Not stated
Classes of Research Reports
Document Development
A workgroup consisting of 6 to 12 members that includes physicians, nurses, pharmacists, and other healthcare professionals relevant to the topic, along with an Institute for Clinical Systems Improvement (ICSI) staff facilitator develops each document. Ordinarily, one of the physicians will be the leader. Most work group members are recruited from ICSI member organizations, but if there is expertise not represented by ICSI members, 1 or 2 members may be recruited from medical groups, hospitals, or other organizations that are not members of ICSI.
The work group will meet for 3 to 4 three-hour meetings to develop the protocol. Under the coordination of the ICSI staff facilitator, the work group develops the algorithm and writes the annotations and literature citations. The literature is graded in the document based on the ICSI Evidence Grading System.
Once the final draft copy of the protocol is developed, the document is sent to the ICSI members for review and comment.
Not applicable
A formal cost analysis was not performed and published cost analyses were not reviewed.
Review and Comment
The purpose of the review and comment process is to provide an opportunity for the clinicians in the member organizations to review the science behind the recommendations and focus on the content of the protocol. Review and comment also provide an opportunity for clinicians in each organization to come to consensus on feedback they wish to give the work group and to consider changes needed across systems in their organization to implement the protocol.
All member organizations are encouraged to provide feedback on protocols; however, responding to review and comment is not a criterion for continued membership within the Institute for Clinical Systems Improvement (ICSI).
Document Approval
Each protocol is approved by the appropriate steering committee. There is a steering committee for Respiratory, Cardiovascular, Women's Health, and Preventive Services. The Committee for Evidence-based Practice approves guidelines, order sets, and protocols not associated with a particular category. The steering committees review and approve each protocol based on:
Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report--January 2012 .
The recommendations for treatment of pressure ulcers are presented in the form of a protocol and two algorithms with 11 components each accompanied by detailed annotations. Algorithms are provided in the original guideline document for Pressure Ulcer Prevention and Treatment (inpatient algorithm) and Pressure Ulcer Prevention and Treatment (outpatient algorithm). Clinical highlights and the annotations follow.
Class of evidence (A-D, M, R, X) ratings are defined at the end of the "Major Recommendations" field.
Clinical Highlights
Special Considerations
Pressure ulcer prevention should be provided for all patients at risk of pressure ulcer development and those individuals who have a pressure ulcer [M]. There may be some patient conditions that may impede interventions in this protocol being implemented. Individualize the interventions as appropriate for these patients.
Risk assessment should be provided for all inpatients and outpatients. The frequency and extent of this assessment varies based on the patient's risk factors.
For inpatients, the risk assessment and skin inspection must be documented in the patient record, and "Not Assessed" should be written if not completed. The pressure ulcer prevention plan must be documented in the patient record and "Not Applicable" written if patient is at minimal risk (e.g., Braden score >18). The other communication and education steps of the protocol still apply.
All personnel involved in the process must take an active role in this protocol. If at any time a particular section of the protocol cannot be performed (e.g., maintain nutrition), the other assessment, verifications and subsequent steps still apply.
Persons undergoing palliative or hospice care may need an alteration in their goals of care. The goals of care can shift from prevention and treatment to palliation and management of ulcer pain and odor [R]. Refer to Annotation # 9, "Identify Treatment Goals," for further discussion.
Special consideration should be given to the use of compression stockings as they can impair lower extremity arterial function [D]. Lower extremity arterial disease should be ruled out before compression is applied. Stockings must be fitted based on measurements of ankle, calf and lower leg length. If the patient's legs are likely to become edematous, they should be measured over several days to be sure initial size of stockings is still appropriate. If the patient complains of pain or tightness of stockings, the legs should be remeasured. Stockings must be removed to inspect the skin for signs of pressure or perfusion problems.
Thigh-high elastic stockings have not proven to be more effective in prevention than knee-high ones and should be avoided because of the tendency to roll and cause a tourniquet effect. Elastic stockings are being used less by hospitals because of sequential compression device use and prophylactic anticoagulation therapy in deep vein thromboembolism prevention.
There are many potential providers involved in pressure ulcer prevention and treatment. This includes but is not limited to physicians, nurses, dietitians and rehabilitation services professionals. It is important to consider timely and appropriate referrals.
Annotations for Pressure Ulcer Treatment
Pressure ulcer assessment includes determining a person's risk for pressure ulcer development and inspection of skin condition, particularly over bony prominences, beneath clothing and under devices.
For all inpatients, assess risk for pressure ulcer development at time of admission using a validated risk assessment tool. The literature and work group recommend the Braden Scale for Predicting Pressure Sore Risk© (Braden Scale) and the Braden Q Scale©, although there are several tools available to assess pressure ulcer risk. Other tools available include the Norton Scale and Waterlow Scale [M].
The Braden Scale for Predicting Pressure Sore Risk (Braden Scale) is the most commonly used validated tool for predicting patients at risk for pressure ulcer development. Although the sensitivity and specificity for predicting pressure ulcer risk are high for the Braden Scale, it serves as an adjunct to clinical judgment regarding each individual. It is important for the health care team to use the Braden score as a guideline in planning interventions aimed at prevention [R].
The Braden Scale was developed and tested for the adult population. The Braden Q is a modified Braden Scale for use in pediatric patients up to age 18 years. The Braden Q consists of seven subscales: mobility, activity, sensory perception, skin moisture, friction and shear, nutrition and tissue perfusion/oxygenation [R]. The Braden Q was tested for validity in a cohort study with children ages 21 days to 8 years in three sites [C].
Reevaluate the risk for pressure ulcer development daily and with any change in level of care or condition such as surgery, transfer to or from intensive care unit, change in nutritional status or level of mobility, or as indicated for your care setting.
See Appendix A, "Braden Scale for Predicting Pressure Sore Risk© (Braden Scale)," Appendix B, "Braden Q Scale©," and Appendix C, "Outpatient Risk Assessment Plan," in the original guideline document.
Assess risk for pressure ulcer development in all patients receiving care in areas such as outpatient, ambulatory care, same-day surgery, emergency room, interventional cardiology or radiology areas, or similar settings.
Increases in population age, severity of illness and comorbidities have resulted in outpatient areas providing care for more patients at risk for pressure ulcer development. Health care services and triage processes may immobilize patients for two or more hours and place the patient at higher risk for pressure ulcer development.
In the absence of a validated outpatient risk assessment tool, the work group recommends assessing the patient using the following questions:
In addition, for young children, is the child demonstrating inadequate tissue perfusion with evidence of skin breakdown?
For a "Yes" response to any question above, initiate a pressure ulcer prevention plan. See Annotation #3, "Pressure Ulcer Prevention Plan, Documentation and Education of Patient and Caregivers." See also Appendix D, "Pressure Ulcer Prevention Plan," in the original guideline document.
Research has identified age as a risk factor for developing pressure ulcers in correlation with factors such as low blood pressure, temperature, and poor protein intake [B]. Advancing age, along with other risk factors, increases the risk for pressure ulcer development. The existence of comorbid conditions such as cardiovascular and endocrine diseases may contribute to increased vulnerability for the development of pressure ulcers. Patients 75 years of age or greater and/or patients with multiple high-risk diagnoses should be advanced to the next level of risk [R]. See Appendix C, " Outpatient Risk Assessment Plan," in the original guideline document.
Inpatient and Outpatient
It is important for members of the health care team to become familiar with patient populations at increased risk for pressure ulcer development [C], [R]. High-risk diagnoses may include but are not limited to:
The effectiveness and success of treatment of pressure ulcers is greatly influenced by pre-existing comorbidities and chronic conditions. Knowledge of comorbidities and chronic conditions and how they impact the healing process by reducing the amount of oxygen, amino acids, vitamins and minerals available at the wound site thereby determine the appropriate interventions for optimum pressure ulcer healing.
Utilize a consistent documentation format to support risk assessment findings, care provision, communication and measurement.
"Not assessed" is written if the risk assessment is delayed or not completed.
The prevention of pressure ulcers incorporates the interventions below:
The interventions and information presented are to be utilized for prevention of pressure ulcer development. See Appendix D, "Pressure Ulcer Prevention Plan," in the original guideline document.
Minimize/Eliminate Friction and Shear
Minimize Pressure (Off-loading)
Immobility is the most significant risk factor for pressure ulcer development. Consider passive range of motion for prevention and treatment of joint contractures and referral to physical therapy/rehabilitation services for additional treatment. Patients who have any degree of immobility should be closely monitored for pressure ulcer development [R].
Patients have greater intensity of pressure over the bony prominences when sitting in a chair, because there is less distribution of weight. Along with increased weight over the bony prominences, there is a tendency for the body to slide in a downward motion, causing shearing and destruction of the soft tissue over the bony prominences. A sitting position includes sitting in bed with head elevation greater than 30 degrees, a cardiac chair, recliner or wheelchair. When in this position, it is important for the patient to shift weight every 15 minutes if he/she is able to do so independently. This includes "small shifts of weight" such as pushing up on their arms, raising or lowering their head slightly to redistribute the weight, or lifting from side to side. If the patient is unable to shift weight independently, his/her position should be changed by care providers on an hourly basis. Remember to utilize chair cushions and consult Physical Therapy/Occupational Therapy for assistance with seating and positioning [R].
Support Surfaces
The work group recommends that hospitals, transitional care units, and nursing homes convert their standard bed mattresses to group I or II prevention mattresses to reduce the incidence of hospital-acquired pressure ulcers.
The work group also recommends consulting a wound specialist or educated skin care team member for the proper and most cost-effective selection of support surfaces.
Patients in Bed:
Patients in Sitting Position:
Manage Moisture
There is an increased attention to the effects of microclimate in pressure ulcer formation and healing. Microclimate is defined as the tissue temperature and relative humidity at the body/support surface junction. Increased body temperature results in a higher metabolic rate in tissue and alters cell growth towards fibroblasts and scarring. The inpatient population with elevated skin temperatures and perspiration is at increased risk for pressure ulcer formation. Microclimate management is important in prevention and healing of pressure ulcers [R].
Maintain Adequate Nutrition/Hydration
Each individual who is at risk for inadequate nutrition should be screened for nutritional status at admission to a health care facility or with a significant change in condition. A valid and reliable tool, such as the Malnutrition Screening Tool (MST) or the Short Nutritional Assessment Questionnaire (SNAQ), may be used to complete a nutrition screen.
Referral to a Registered Dietitian should take place to thoroughly assess a patient who is at risk for the development of, or presents with, a pressure ulcer [R].
Referral to other health care team members, such as a physician, dentist, speech or occupational therapist, may be needed to evaluate factors contributing to poor nutrition.
Complete an assessment for the prevention or treatment of pressure ulcers, which includes:
The nutrition care plan is built based on the results of the assessment. This care plan would be used for both those patients identified at risk and in need of nutrition prevention, and those patients requiring nutrition intervention of pressure ulcers.
Laboratory values, such as albumin, prealbumin and transferrin may not reflect the current nutritional state, especially in the critically ill patient. Other assessment factors such as weight loss, illness severity, comorbid conditions and gastrointestinal function should be considered for a nutrition plan of care [R].
Educate Patient/Caregivers
Patient education is an important piece of pressure ulcer prevention and treatment. The patient, family and caregivers are key to prevention, management and treatment of pressure ulcers. Teaching materials should be given to the patient and family on admission or at the time risk is identified. Possible content of education includes:
Education should be in an appropriate reading level, organized, appealing and with easy-to-understand instructions in multiple languages and/or family and caregivers should be brought into the hospital to have hands-on teaching on dressing changes to assess their ability to provide the care at home. Detailed written instructions should also be given to them to refer to at home. If the patient, family or caregiver is unable to do the actual treatment, the education still needs to be provided. Education should also be provided to the person or agency that will be doing the care, if the patient, family or caregiver is not able. Document response to education.
Document the pressure ulcer prevention plan in the patient record. Utilize a consistent documentation format to communicate the assessment and care plan. A paper checklist or process within an electronic medical record system could be a tool to support documentation of the pressure ulcer prevention plan.
"Not applicable" is written for the pressure ulcer prevention plan if the patient is not at risk.
All personnel involved in the process must take an active role in the prevention plan. If at any time, a particular section of the plan cannot be implemented (e.g., maintain nutrition), the other interventions still apply.
Refer to the original guideline document for more information about pressure ulcer prevention plan, documentation, and patient/caregiver education.
For all inpatients, complete a skin inspection on every inpatient within six hours of admission, and palpate particularly over bony prominences [R].
For all patients inspect and palpate for:
Caregivers who are not of the same ethnic background as the patient may be less sensitive to slight changes in skin color. This is an important factor to consider in the assessment of patients with darkly pigmented skin [R].
Observe skin in good lighting, and any areas of discoloration or redness should be palpated for change in temperature compared to surrounding skin, or feeling of bogginess (soft) or induration (hard). Pay particular attention to areas over bony prominences. Blanching erythema is an early indicator of the need to redistribute pressure; non-blanching erythema is suggestive that tissue damage has already occurred or is imminent; indurated or boggy skin is a sign that deep tissue damage has likely occurred. Medical devices can cause pressure damage; therefore, close observation around and under medical devices is highly recommended [R].
Re-inspect and palpate skin for inpatients every 8 to 24 hours, depending on status of patient. Frequency of skin inspection under equipment may be different from head-to-toe skin inspection. Depending on the device, an increase frequency may be necessary.
Patients at high risk of breakdown, as determined by either Braden or Braden Q Scale score, may need to be assessed more frequently as condition changes.
The skin inspection can be performed at the same time as other assessments. Start at the top and work downward. A full-body skin inspection doesn't have to be visualizing all aspects of the patient in the same time period.
Refer to the original guideline document for additional information about skin inspection.
Document skin inspection in the patient record. Utilize a consistent documentation format to support care provision, communication and measurement.
"Not assessed" is written if the skin inspection is delayed or not completed. Define a procedure for documentation of a patient refusal of skin inspection. The communication and education steps of the protocol apply even if skin inspection is refused by the patient.
A paper checklist or process within an electronic medical record system could be a tool to support documentation of skin inspection.
The scope of this guideline is limited to the evaluation and treatment of pressure ulcers defined as 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 friction. Wound types outside of scope, though they share pressure and shear as a portion of their etiology, include:
Pressure ulcer treatment includes an assessment of the following elements: history and physical, etiology of pressure, psychosocial needs, nutritional status, wound and surrounding skin appearance, and bacterial colonization/infection.
History and Physical
Review a current health history and physical including medication list to identify factors potentially contributing to the pressure ulcer or impairing the healing of the pressure ulcer. For example, patients with atherosclerotic cardiovascular disease or low blood pressure may not perfuse tissue at normal levels and therefore would be at higher risk of developing pressure ulcers. Also, patients who use tobacco or have low hemoglobin would have reduced oxygen transported to cells, thus increasing the risk of cell death. Diabetes can cause microvascular disease and loss of protective sensation of the lower extremities, both contributing factors in the development of pressure ulcers. Neurological injuries from stroke and spinal cord injury or deficits in mobility or level of consciousness could interfere with the patient's ability to reposition or sense/indicate discomfort. The subscales of validated risk assessment tools guide practitioners to the areas of risk and need for intervention [C].
Wound Description/Staging
Pressure ulcer assessment consists of an assessment of the wound and surrounding (periwound) skin.
Thorough assessment of the wound should occur when the wound is initially identified, routinely and prior to any transition from one health care setting to another. This transition assessment is essential to communicate clearly to the next level of care regarding the state of the wound.
Clean the wound and surrounding skin prior to assessment. With each dressing change, assess the wound bed appearance, surrounding skin, and drainage. Document the assessment findings.
Refer to the Resources Table in the original guideline document for National Database of Nursing Quality Indicators (NDNQI)-related resources.
Etiology of Pressure
Identifying the source of pressure is essential as a preventive measure or when an injury is suspected. Although the most common locations of pressure ulcers are bony prominences, equipment-related pressure ulcers are increasing. Devices that may contribute to pressure ulcers include respiratory therapy equipment, compression therapy devices, and immobilizing equipment.
When the patient's overall health status supports healing, yet no improvement in the wound has been noted, the source of pressure may not have been correctly identified, and therefore the interventions may not be effective.
Nutritional Status
Nutritional needs are based on the patient's age, sex, height, weight, presence of inadequate nutrition or obesity, current disease state, severity of illness, and presence and severity of wounds. The work group recommends collecting a baseline nutritional assessment. Refer to Annotation #3, "Pressure Ulcer Prevention Plan, Documentation and Education of Patient and Caregivers," for more specific information on nutritional assessment.
Bacterial Colonization/Infection
It is important to differentiate between wound contamination, colonization, and infection. Contamination is the presence of bacteria on the wound surface without proliferation. Colonization is characterized by the presence and proliferation of microorganisms in a wound without a host response. This occurs frequently, particularly in chronic wounds such as stasis ulcers, and pressure ulcers [R]. Critical colonization is an elevated or "critical" level of surface colonization that can delay wound healing without eliciting a host immune response, as infection would [R].
A wound infection occurs when the bacteria invade healthy viable tissue to proliferate to the point of overwhelming the host's immune response. The infection may be acute or chronic depending on the host's defense mechanisms [R].
In acute wounds, the classic signs of inflammation (redness, edema, pain, increased exudate, and periwound surface warmth) persist beyond the normal time frame of three to four days. In patients who are immunosuppressed, the signs of inflammation often are diminished or masked because these patients are unable to mount an effective immune response. Often the only clue to a wound infection is complaint of pain.
All chronic wounds, including pressure ulcers, have bacteria. The clinician needs to determine if the bacterial load in the wound is balanced or has critical colonization or infection. Since bacteria resides in non-viable tissue, debridement of this tissue and wound cleansing are important to reduce bacteria and avoid adverse outcomes such as sepsis.
The first sign of critical colonization or local infection may be a delay in healing and an increase in exudates. Critical colonization potentially can be treated with antimicrobial dressings such as silver preparations.
Diagnosis of wound infections is based on patient history and clinical findings. Although the gold standard for determining infection is tissue biopsy, many wounds are swab cultured for confirmation of infection. All wounds should be cleansed with a non-antiseptic solution prior to culture [R]. The swab culture should be placed on healthy granulation tissue, pressed down and turned 360 degrees to extract fluid. Do not culture pus, slough or necrotic tissue [R]. Infection is indicated when bacteria counts reach 105 organism per gram of tissue. Infection must be treated with systemic antibiotics based on wound culture results. The signs and symptoms of wound infection depend on whether the wound is acute or chronic [R].
In a chronic wound, the signs of infection may be more subtle. Signs may be:
Clinicians may find the mnemonics NERDS and STONES helpful. See Appendix E, "Mnemonics for Critical Colonization," in the original guideline document.
See the original guideline document for information on biofilm.
Psychosocial Needs
Psychosocial issues may affect pressure ulcer development and treatment. One study reported that increased isolation from friends and family, financial problems, pain, lack of privacy, changes in body image and loss of control and independence have significant impact on the patient and their recovery [D]. Lower levels of well-being and activity in spinal cord injury and pressure ulcer development have been reported [D]. There is some evidence to support that psychological factors may influence the development of pressure ulcers, and an individual's style of coping may have an effect on outcomes [D].
Providing holistic care through empathy, knowledge, and tailoring the plan of care to the patient's individual needs will facilitate physical healing as well as the spiritual healing [D]. Interventions to enhance socialization such as encouraging involvement in current relationships, in developing relationships, and positive feedback when the patient reaches out to others might be beneficial [R]. Interventions to enhance body image would include assisting patients to discuss changes caused by the pressure ulcer and assisting patient to separate physical appearance from feelings of personal worth [R]. Pain management, financial assistance and providing privacy may also help to enhance the patient's psychosocial adjustment to the pressure ulcer.
Determine if the patient is able to manage the wound treatment independently or if he/she has adequate support at home. Consider referral for additional resources/services as necessary.
For inpatients, a thorough wound assessment (as described above) is documented on admission or initial identification of a hospital-acquired pressure ulcer, and prior to any transition from one health care setting to another. Partial wound assessment is documented with each dressing change. Dressing status is documented every shift. If advanced wound dressings are in place on day of discharge, the previous dressing change assessment is also noted.
Documentation is recorded in the outpatient medical record according to organizational policy.
A consistent documentation format is utilized to support care provision, communication and measurement.
A paper checklist or process within an electronic medical record system could be a tool to support documentation of the assessment.
Document turning and repositioning, as well as lack of them due to patient refusal, contraindications or inability to comply.
Wound healing or restorative care is the optimal goal that is evidenced by granulation tissue or re-epithelialization of the wound [R]. This goal is obtained by evidenced-based interventions that support the principles of wound healing. For palliative care, the individual's wishes are followed, and the goals promote comfort.
The treatment goal directs the plan of care, including, but not limited to:
Wound palliation or symptom management is the goal for those wounds that have become chronic and do not respond to standard interventions or when the demands of the treatment are beyond the patient's tolerance or stamina, such as in the end-of-life issues. The following mnemonics identify the components of a treatment plan for symptom management [R]:
S = Stabilize the wound
P = Prevent new wounds
E = Eliminate odor
C = Control pain
I = Infection prophylaxis
A = Advanced absorbent wound dressing
L = Lessen dressing changes as palliation care occurs
Many of the interventions of a treatment plan to heal a wound are not possible with a patient who is receiving palliative care. The focus is to manage pain, drainage and odor, as well as prevention of complications/deterioration of wound. If the patient is receiving comfort care, advanced wound care may be used in these situations and may include:
Individualize turning and repositioning per the patient's preferences, goals and as the medical patient's condition allows. Utilize pressure redistribution, padding and positioning devices.
Moist Wound Healing
A moist wound surface promotes cell migration and prevents cell death. The clinician must select agents that maintain or donate moisture at the wound surface. The cardinal rule of healing is to keep the wound tissue moist and the surrounding skin dry. Use a dressing that will keep the wound bed continuously moist. A wet-to-dry dressing is not typically considered continuously moist and therefore not recommended [B], [R], [NA].
The work group recommends the following tips:
Wound Cleansing
Wound healing is optimized and risk of infection is reduced when surface bacteria, necrotic tissue, exudates, metabolic wastes, and residue of wound care products are removed from the wound. Routine wound cleansing is used for both necrotic and clean wounds. Routine wound cleansing should be accomplished with minimal chemical or mechanical trauma to the tissue [M]. Traumatized wounds have a greater risk of infection and slower healing rate. The process of cleansing a wound involves selection of both a wound cleansing solution and a mechanical means of delivering that solution to the wound.
Goals of Cleansing
General Points of Cleansing
Mechanical Cleansing Procedure
Work in a circular pattern, starting at the center of the wound to gently cleanse the wound with the moistened gauze. Work toward the edge of the wound and surrounding skin. Remove loose tissue with the gauze pad. Do not press hard or scrub a clean wound because this will damage the tissue and slow healing. Do not return to the wound center after cleansing, to avoid recontamination of the wound.
Antimicrobials and Cleansers
Normal saline is a safe and effective cleanser for all wounds. Normal saline is physiologic and will not harm tissue. It will adequately cleanse most wounds if a sufficient amount is used to thoroughly flush the wound. Although normal saline is the cleanser of choice in the hospital, it does not contain a preservative, so bacteria starts to colonize once the sealed bottle is open. Therefore, hospital protocols often advise discarding any unused saline after 24 hours.
Drinkable tap water is as effective as saline to cleanse a wound. Cleansing can be done under running water in a sink or preferably in the shower. Immunosuppressed patients should not use tap water [M].
For the clean granulating wound, cytotoxic cleaning agents are not indicated. However, when a wound is suspected to have critical colonization or infection, topical antimicrobials are indicated (e.g., povidone-iodine, sodium hypochlorite solution, hydrogen peroxide or acetic acid) for a time-limited period (usually two weeks) [R]. For wounds with evidence of a heavy bioburden, use agents and dilutions that minimize any adverse effects. Discontinue the antimicrobial as soon as the bacterial balance has been restored, as evidenced by a clean wound bed and a reduced volume of exudate. If the wound has heavy exudates or adherent material, a commercial wound cleanser may be used. Commercial wound cleansers contain surfactants that help remove wound contaminants [R].
High-pressure irrigation may be needed in the presence of slough and necrotic tissue [R].
Periwound Skin Cleansing
Periwound skin must be protected throughout the healing process. Trauma, excoriation, erythema, maceration, and dermatitis of intact skin delay epithelial activity and increase pain. Periwound maceration and continuous contact with wound moisture can enlarge the wound and impede healing [R]. Special attention to the periwound skin should be part of all dressing changes. Barrier ointments or films, absorptive dressings, and hydrocolloids can be used to protect the periwound skin. Cleaning the periwound skin with a pH balanced skin cleanser rather than saline promotes the healing of pressure ulcers [D]. Intact skin should be moisturized regularly to prevent cracking of the skin.
Topical Treatments
Dressing selection should be based on the tissue in the wound bed, the periwound skin condition and the treatment goals. The type of dressing may change over time as the wound heals or deteriorates [R].
Refer to the original guideline document for more information on these products.
Debridement is the removal of necrotic tissue or contaminated foreign matter. Necrotic tissue is non-viable, devitalized tissue called slough or eschar and varies in color, consistency and adherence to the wound bed. The words "slough" and "eschar" refer to different levels of necrosis and are described according to color and consistency. Slough is described as yellow (or tan) and thin, mucinous or stringy; eschar is described as brown or black and soft or hard, and represents full-thickness destruction [D], [R]. Slough tends to have more moisture and less adherence to the wound bed than eschar, having little to no moisture and much adherence [R].
Necrotic tissue impedes wound healing for two main reasons: 1) it is a medium for bacterial growth, and 2) is a physical obstruction or barrier to granulation, contraction and epithelialization in the wound bed [D], [R], [NA].
Goals of Debridement
Selective Debridement
Refer to the original guideline document for more information on selective types of debridement.
Non-selective Debridement
Surgical sharp debridement is preferred for larger or deeper pressure ulcers to quickly shift the state of the wound from burdened, infected or chronic healing to free to proliferate in a normal or acute healing process. This, of course, depends on the status of the patient and the surgeon's clinical judgment. Prior to performing any type of debridement of the extremities, especially below the knee, the patient must be assessed for adequate blood supply by palpation of pulses, Doppler, ankle/brachial index, non-invasive arterial studies and a review of the patient's past and present medical history for risk factors for arterial insufficiency. Surgical debridement is the excision of necrotic material up to and including viable tissue margins [R]. International guidelines recommend performing debridement in the operating room for the following situations: presence of advancing cellulitis, wound-related sepsis, extensive necrotic tissue, inability to establish degree of undermining/tunneling, and if there is infected bone or hardware that may require removal [R].
Mechanical debridement is the removal of necrotic tissue using an outside force. The most common types of mechanical debridement are wet-to-dry gauze dressings (distinct from wet-to-moist gauze dressings where the wound bed and primary layer of the dressing remain completely moist and do not adhere to each other), wound irrigation (using a blunt needle and syringe or pulsed lavage with suction), and whirlpool.
Refer to the original guideline document for additional information on debridement.
Adjunct Therapies
Adjunct therapies can augment the healing process for pressure ulcers in any phase of wound healing, as long as the standard of care is implemented concomitantly. For example, using electrical stimulation on a pressure ulcer in the absence of off-loading will do little for creating a positive outcome for the patient. The original guideline document provides a description of adjunct therapies for the reader to explore and to make the appropriate referral to a clinician trained in their use, but does not necessarily constitute a "recommendation" by the work group. Note: there is little data comparing the use of one adjunct therapy to another.
Biophysical Agents
Biophysical agents or modalities such as electrical stimulation; induced electrical stimulation; photo therapy, i.e., infrared and ultraviolet; negative pressure wound therapy; hyperbaric oxygen; and non-contact, non-thermal ultrasound all add some form of energy to the wound bed to help drive the healing process forward, especially in the compromised tissues of patients who tend to get pressure ulcers.
Electrical stimulation for wound healing is defined as the use of a capacitative coupled electrical current to transfer energy to a wound. A physical therapist will have the knowledge required to set the polarity, amplitude and voltage, amperage, wave forms, frequency and duty cycle appropriate for the state of each wound and patient. There is a significant body of research that demonstrates that polarity influences healing in different ways at different phases [R]. Electrical stimulation also improves local blood flow and oxygen delivery, has antibacterial effects, helps with debridement and thrombolysis, and decreases pain. Contraindications are malignancy, an electronic implant or metal implant. Consider the use of direct contact (capacitative) electrical stimulation in the management of recalcitrant category/stage II, as well as category/stage III and IV pressure ulcers to facilitate wound healing.
Induced electrical stimulation is technology that induces the flow of electrons in the tissue rather than directly applying electricity. These technologies are pulsed radio frequency stimulation, pulsed electromagnetic fields, and pulsed short-wave diathermy. All of these are forms of diathermy, but for wound healing are set up, and applied, to be non-thermal. All class III diathermy non-thermal medical devices licensed by the Federal Drug Administration induce electrical current in the tissues, and as such, will have the same clinical effects, indications and contraindications as direct electrical stimulation [R].
Hyperbaric oxygen therapy is the application of oxygen to the host's tissues above atmospheric pressure. Systemic hyperbaric oxygen is administered by a Certified Hyperbaric Registered Nurse (CHRN) or a Certified Hyperbaric Technologist (CHT). Hyperbaric oxygen is generally not the first adjunct therapy considered since wound ischemia is due to pressure that should be eliminated through support surfaces, splinting and positioning. If off-loading measures are adequate, the wound should get enough perfusion, as long as no arterial insufficiency is present. If a pressure ulcer is present distal to the knee, check for adequate blood flow [R].
Negative pressure wound therapy devices apply negative pressure, or suction, to the wound bed. This technology should be applied by a clinician (registered nurse, physical therapist, physician, podiatrist, etc.) trained in its indications, contraindications, precautions and different methods of application. It is a skilled application, with risk if not done properly, and it should also be monitored by clinician for any adverse outcomes or events, specifically frank bleeding from a named vessel or organ.
Refer to the original guideline document for additional information on the mechanism of action of different types of biophysical modalities.
Biological Applications
These are products that donate physiological constituents in wound healing to the wound bed. They can donate extra cellular matrices, cells of repair, cellular communicators, and growth factors. They take the form of gels and sheets placed in the wound bed that is prepared: free of necrosis and bacterial bioburden. These products are an attempt to modulate chronic wound physiology, moving it forward into a more normal rate of repair by providing the wound with resources it otherwise did not have or is slow to recruit. Categories are platelet gels, platelet-derived growth factor therapy, biological skin substitutes, and extracellular matrix sheets. For these products, it is recommended that clinicians refer the patient to a wound-focused physician or clinician, who will be able to help select the appropriate product.
Pain Management
Pressure ulcers can be extremely painful, and it is important to assess every patient with a pressure ulcer for pain [D]. Wound pain may be decreased by maintaining a moist wound bed or by using non-adherent dressings. Some dressings, such as hydrogels or foams, may cause less pain and require less frequent dressing changes. Assessment of the pain component of a wound should occur at regular intervals, such as on admission, with reassessments, with routine vital signs, with changes in activity level, with dressing changes, and after painful interventions [D]. Pharmacological and non-pharmacological pain relief measures should be considered to treat the pain associated with a pressure ulcer or with the interventions needed to treat the ulcer. Consider premedication for effective pain management prior to implementing any wound care, especially with debridement. Use of analgesics and adjunctive therapies are important interventions to consider in alleviating the painful experience. Two small studies indicate topical opioids may be a consideration for reducing pressure ulcer pain [A], [D]. Non-pharmacologic interventions could include repositioning, positioning off the pressure ulcer, using effective safe-handling devices such as lift devices or transfer sheets, use of pressure redistribution devices, relaxation techniques, guided imagery, music therapy, and distraction [D].
Specific Nutrient Goals for Treatment of Pressure Ulcer
Treatment plans for the nutritional needs of persons with pressure ulcers include:
Therapeutic Vitamin and Mineral Supplement
Daily administration may be considered if poor oral intake or deficiencies are suspected based on patient history or lab assays. This supplementation may contain recommended vitamin C dosage [R].
Biochemical Data
Serum albumin and prealbumin may be useful to establish overall health. However the results are also reflective of other disease states such as liver disease hydration or renal disease. This needs to be taken into account as the levels may not correlate to nutritional status [R].
Arginine and Glutamine
Supplemental use of arginine and glutamine is controversial and more studies need to be undertaken; at this time supplementations are not recommended [R].
Vitamin A
Excessive vitamin A supplementation can lead to an exacerbated inflammatory response. Also, in patients with chronic renal failure, vitamin A supplementation is frequently contraindicated as vitamin A levels are typically high in this population, and there is an increased risk of hypercalcemia. Patients with fat malabsorption may require a water-miscible form of vitamin A. Discuss supplementation of vitamin A with a registered dietitian or physician to address correct dosage [R]. Therapeutic vitamin and mineral supplement may provide vitamin A at daily requirement needs.
Surgical Repair
Pressure ulcers may be closed using surgical intervention in certain circumstances. When there is significant tissue loss, a flap procedure by a plastic surgeon is typically performed. Surgical repair of stage III or IV pressure ulcers is considered when other therapies have been implemented and patient healing is optimal. Recommendation is to consult a surgeon who is experienced in surgical repair of pressure ulcers.
Patient Education
Education should be in an appropriate reading level, organized, appealing and with easy-to-understand instructions. Family and caregivers should be brought into the hospital to have hands-on teaching on dressing changes to assess their ability to provide the care at home. Detailed written instructions should also be given to them to refer to at home. If the patient, family or caregiver is unable to do the actual treatment, the education still needs to be provided. Education should also be provided to the person or agency that will be doing the care, if the patient, family or caregiver is not able. Document response to education.
All health care team members need to be aware of patients who are at risk for pressure ulcers and those with active safety plans. Communicate skin status and prevention plan interventions when transferring care to another provider such as change of shifts, transporting between departments, and patient transfer to another facility or unit. Develop a method to communicate skin care concerns to all members of the health care team. Use consistent methods for communication, such as identifying the Braden score or Braden Q score and skin inspection results.
Discharge Plan or Transfer of Care
At discharge or transfer of care to another department or facility, the patient's plan of care – including a thorough description, goal of treatment, stage of ulcer and follow-up should be communicated. Location, size, type, stage, description of wound bed and surrounding skin along with past and current treatments should be communicated to ensure continuity of care and to decrease chance of further injury and delay of healing. If the patient is at risk, special needs and interventions used should be communicated. The needs of the patient at home or place of discharge need to be assessed to ensure the patient has equipment and resources available. This includes specialty surfaces in bed and chair, wound supplies, nutritional needs, and transfer equipment.
The following detailed and annotated clinical algorithms are provided in the original guideline document :
The type of supporting evidence is classified for selected recommendations (see the "Major Recommendations" field).
Appropriate prevention and treatment of pressure ulcers in an acute healthcare facility and ambulatory settings
Once a guideline is approved for release, a member group can choose to concentrate on the implementation of that guideline. When four or more groups choose the same guideline to implement and they wish to collaborate with others, they may form an action group.
In the action group, each medical group sets specific goals they plan to achieve in improving patient care based on the particular guideline(s). Each medical group shares its experiences and supporting measurement results within the action group. This sharing facilitates a collaborative learning environment. Action group learnings are also documented and shared with interested medical groups within the collaborative.
Currently, action groups may focus on one guideline or a set of guidelines such as hypertension, lipid treatment, and tobacco cessation.
Detailed measurement strategies are presented in the original guideline document to help close the gap between clinical practice and the guideline recommendations. Summaries of the measures are provided in the National Quality Measures Clearinghouse (NQMC).
Implementation Recommendations
Prior to implementation, it is important to consider current organizational infrastructure that address the following:
The following system changes were identified by the work group as key strategies for health care systems to incorporate in support of the implementation of this protocol.
The Institute for Clinical Systems Improvement (ICSI) Pressure Ulcer work group identified barriers to implementing pressure ulcer prevention and treatment plans. The work group agreed on the universality of the issues and on the need to address them. The issues and recommendations for addressing them are stated below.
Gaps in communication exist in varying degrees throughout systems.
Possible activities to address barriers:
Patient Complexity
The ability to prevent pressure ulcer development is affected by the complexity and acuity of patient disease states, physical condition, aging population, obesity and malnutrition, and necessary supporting equipment that may vary during hospitalization.
Patient Physical and Behavioral Compliance
The ability of patients to participate in pressure ulcer prevention strategies may be affected by physical and behavioral factors. Noncompliance may be related to inability to participate, lifestyle issues, cultural differences, medical condition, physical condition, lack of trust or knowledge gaps.
Technical Components
Equipment and supplies needed for pressure ulcer prevention and treatment may not be readily available.
Implementing consistent processes for pressure ulcer assessment and prevention may be viewed as additional work.
Knowledge Deficit
Pressure ulcer prevention is complex. Conflicting procedures and protocols may exist. Multiple health care team members may be involved in caring for the patient, and limited knowledge may result in misunderstanding of equipment or procedures. Consistent risk assessment and initiation of prevention strategies are challenges.
Refer to the original guideline document for information on continuous quality improvement strategies.
Not applicable: The guideline was not adapted from another source.
Organizations participating in the Institute for Clinical Systems Improvement (ICSI): Organizations participating in the Institute for Clinical Systems Improvement (ICSI): Affiliated Community Medical Centers; Allina Medical Clinic; Aspen Medical Group; Baldwin Area Medical Center; Brown Clinic; Center for Diagnostic Imaging/Medical Scanning Consultants; CentraCare; Central Lakes Medical Clinic; Chippewa County – Montevideo Hospital & Clinic; Cuyuna Regional Medical Center; Essentia Health; Fairview Health Services; Family HealthServices Minnesota; Family Practice Medical Center; Fergus Falls Medical Clinic; Gillette Children's Specialty Healthcare; Grand Itasca Clinic and Hospital; Hamm Clinic; HealthEast Care System; HealthPartners Central Minnesota Clinics; HealthPartners Medical Group & Regions Hospital; Hennepin County Medical Center; Hennepin Faculty Associates; Howard Young Medical Center; Hudson Physicians; Hutchinson Area Health Care; Hutchinson Medical Center; Integrity Health Network; Lake Region Healthcare Corporation; Lakeview Clinic; Mankato Clinic; MAPS Medical Pain Clinics; Marshfield Clinic; Mayo Clinic; Mercy Hospital and Health Care Center; Midwest Spine Institute; Minnesota Association of Community Health Centers; Minnesota Gastroenterology; Multicare Associates; New Richmond Clinic; North Central Heart Institute; North Clinic; North Memorial Health Care; Northwest Family Physicians; Obstetrics and Gynecology Specialists; Olmsted Medical Center; Park Nicollet Health Services; Planned Parenthood Minnesota, North Dakota, South Dakota; Quello Clinic; Raiter Clinic; Rice Memorial Hospital; Ridgeview Medical Center; River Falls Medical Clinic; Riverwood Healthcare Center; South Lake Pediatrics; Southside Community Health Services; Stillwater Medical Group; University of Minnesota Physicians; Winona Health
ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: firstname.lastname@example.com; Web site: www.icsi.org .
The following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, Security Health Plan of Wisconsin, and UCare. In-kind support is provided by the Institute for Clinical Systems Improvement's (ICSI) members.
Patient Safety & Reliability Steering Committee
Work Group Members: Deb Perry, RN (Work Group Leader) (Olmsted Medical Center) (Nursing); Kathleen Borchert, MS, RN, CWOCN, ACNS-BC (Certified Wound Care Specialist) (HealthEast Care System); Bhavin Patel, MD (HealthPartners Medical Group and Regions Hospital) (Internal Medicine); Sandy Burke, RN (Olmsted Medical Center) (Nursing); Katherine Chick, RN, CNS (Mayo Clinic) (Nursing); Wendy Kraft, RN, BSN, CWOCN (North Memorial) (Nursing); Susan Thompson, MS, RN (Mayo Clinic) (Nursing); Kari Retzer, RN (Institute for Clinical Systems Improvement) (Facilitator)
In the interest of full disclosure, Institute for Clinical Systems Improvement (ICSI) has adopted a policy of revealing relationships work group members have with companies that sell products or services that are relevant to this protocol topic. It is not assumed that these financial interests will have an adverse impact on content. They are simply noted here to fully inform users of the protocol.
Kathy Borchert, MS, RN, CWOCN, ACNS-BC, reviews documentation and provides expert testimony related to pressure ulcer cases.
No other work group members have potential conflicts of interest to disclose.
Electronic copies: None available.
Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425.
The following is available:
Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org ; e-mail: email@example.com.
In addition, the Braden Scale for Predicting Pressure Sore Risk, the Braden Q Scale tools, an outpatient risk assessment plan, a pressure ulcer prevention plan, and mnemonics for critical colonization are available in the appendices of the original guideline document.
None available
This NGC summary was completed by ECRI Institute on July 28, 2009. This NGC summary was updated by ECRI Institute on October 20, 2010. This summary was updated by ECRI Institute on March 16, 2011 following the U.S. Food and Drug Administration advisory on negative pressure wound therapy (NPWT) systems. This NGC summary was updated by ECRI Institute on May 25, 2012. This summary was updated by ECRI Institute on March 6, 2014 following the U.S. Food and Drug Administration advisory on Over-the-Counter Topical Antiseptic Products. This summary was updated by ECRI Institute on June 2, 2016 following the U.S. Food and Drug Administration advisory on Opioid pain medicines.
This NGC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Guideline) is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
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There has been a catastrophic rise in the incidence of type 2 diabetes over the years. A great deal of this problem has been associated with being overweight and obese due to poor diets and lack of enough exercise. Research has found fish derived serum omega-3 fatty acids may help reduce the risk of type 2 diabetes, reported Bioscience Technology on Jan. 14, 2014.
According to a University of Eastern Finland study, high concentrations of serum long-chain omega-3 fatty acids may help lower the risk of type 2 diabetes. It has been found by earlier research that weight management, exercise and high serum linoleic acid concentrations, among other things, are associated with a lowered risk of diabetes. However, findings dealing with how fish consumption or long-chain omega-3 fatty acids affect the risk which is associated with diabetes have been highly contradictory.
A study by University of Eastern Finland researchers has offered new insights into the association which exists between fish consumption and the risk of type 2 diabetes. In a well balanced diet there should be at least two fish meals per week, preferably consisting of fatty fish. Salmon, rainbow trout, herring, anchovy, sardine and mackerel are rich in long-chain omega-3 fatty acids. The cornerstones of diabetes prevention center around weight management, increased exercise and a well-rounded diet.
Omega-3 fatty acids are polyunsaturated fatty acids which are essential nutrients for good health, reports the Harvard School of Public Health. Omega-3 fatty acids are important for many normal body functions, such as controlling blood clotting and building cell membranes in the brain. Omega-3 fatty acids have also been found to be associated with many health benefits, including protection against heart disease and possibly stroke.
New studies have found potential benefits of omega-3 fatty acids for many others conditions including cancer, inflammatory bowel disease, and other autoimmune diseases such as lupus and rheumatoid arthritis. This new study in Finland adds type 2 diabetes to the list of diseases omega-3 fatty acids may benefit. Dr Harold Mandel Online offers fish oil supplement, which is a rich source of omega-3 fatty acids, for sale online.


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How 'headless Android' is revolutionizing embedded systems development
What is a "headless Android" and how is it revolutionizing embedded systems development? These are the questions TheServerSide asked Karim Yaghmour (@karimyaghmour), author of Bulding Embedded Linux Systems and an expert on the emerging trend of making Android the platform of choice in the embedded space. We spoke to him about the future of Linux, Android and the proliferation of embedded devices.
Follow Cameron
McKenzie on Twitter (@potemcam)
Head First Mobile Web by Lyza Danger Gardner
Professional Android 4 Application Development by Reto Meier
Mobile Development with C#: iOS, Android, and Windows Phone by Greg Shackles
What's New in Java 7? by Madhusudhan Konda
The Well-Grounded Java Developer By Martijn Verburg
20 Feb 2013


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While most visitors to the downstairs galleries at the Legion come for the superb "Intimate Impressionism" show, another exquisite exhibit is on view in one of the small side galleries. Chosen from the collection of the Achenbach Foundation for Graphic Arts (AFGA), the Logan Gallery is showing seven of Matisse's illustrated books.
Henri Matisse was 60 years old when he began to create original illustrations for livres d'artiste (artists' books). By the time of his death, 25 years later, he had produced more than a dozen illustrated books, deluxe, limited editions, meant to be collected and admired as works of art, as well as, read.
Matisse was stimulated and challenged by book illustration and design, often taking months to prepare pictorial concepts. In his 1946 essay "How I Did My Books," he wrote, "I draw no distinction between the construction of a book and the construction of a painting and always move from the simple to the complex, but I am always ready to reconceive in simplicity."
In the same essay he declared that the first principle of good book design was a rapport with the nature of the book. For Matisse this meant carefully balancing text and illustration. He handled this masterfully in "Pasiphaé" with delicate linocuts, and in "Poésies" with etchings composed of modified arabesques that draw attention to the illustration as much as to the inviting text.
Matisse took his first step in illustration when Swiss publisher Skira approached him in 1930 to illustrate the work "Poésies," by 19th century French poet Stéphane Mallarmé. Matisse responded to Skira's invitation with great enthusiasm and that summer, devoted most of his attention to the commission while he was residing in Paris. He made an enormous number of drawings for the project. Of these, 27 drawings were chosen to be engraved. Matisse said that he used the extraordinary economy of the thin, engraved line with no shading whatsoever in order not to overpower the etherial quality of Mallarmé's poetry. Matisse's etchings of Mallarmé's poems are considered among his greatest works in the print medium.
The last book Matisse illustrated, with color lithographs, was an anthology of poetry by Charles d'Orleans in 1950. Charles d'Orléans, a member of the French royal family of Valois, has been called the father of French lyric poetry and reputedly the sender of the first valentine. The chief subject matter of his poetry was courtly love and separation, written in such a veiled way that the unknown woman could be one of, or a conflation of, his two wives, a mistress or the land of France itself.
"Matisse and the artist book" displays seven of these rare books, including "Poésies" (1932) and "Pasiphaé" (1944), in conjunction with the special exhibition "Matisse from SFMOMA" at the Legion of Honor.
Happy Birthday Van Gogh - the only Van Gogh on view in the Bay Area is at the Legion of Honor as part of the "Intimate Impressionism" exhibit.


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HOLLYWOOD -- "I'm nuts, I'm weird but I'm great."
That was Al Pacino in a 1974 interview with the South African publication, Cinema & TV.
Three decades ago it was hard to disagree with him about the "great" part.
Sure, he had a reputation for being a bit on the intense side, but by 1974, his work already spoke for itself -- the first two Godfather movies, Serpico and Panic in Needle Park, with Dog Day Afternoon waiting in the wings.
It's important to remember that when taking in 88 Minutes (if one must), Pacino's latest -- and arguably lamest effort yet in his current career downward spiral.
Watching him as a forensic scientist who's informed he has less than an hour-and-a-half to live in this C-grade thriller, it's hard to pinpoint what's worse: The script, the acting or Pacino's gravity-defying hairdo, which seems to float atop his skull like a hirsute hovercraft.
Did he really put his artistic credibility on the line for the $9 million salary he was rumoured to have received for this nonsense?
If so, maybe the hair-don't was his way of signaling to his fans that it was really just about the money.
After all, legend has it the late, great Orson Welles was known to wear a fake nose every time he took on a role solely for the big paycheck, which would go toward funding his own personal projects.
Then again, that would represent an awful lot of hairspray given Pacino's output over much of the new millennium.
With the exception of 2002's terrific Insomnia, the duds have just kept on coming, including S1MONE, People I Know, the appropriately named Two for the Money and, oh yeah, a crazy little thing called Gigli.
To be fair, 68-year-old Pacino isn't the only heralded actor of the '70s who has made some dubious choices over the years.
Contemporary Robert De Niro has made his share of recent blunders -- Hide and Seek, anyone? -- but he's also managed to shrewdly send up his tough-guy image in Meet the Parents/Fokkers and Analyze This/That with considerable commercial success.
Likewise Jack Nicholson, who despite his growing tendency to "Jack up" a role, still possesses the ability to hunker down and deliver that old Jack magic in movies such as About Schmidt and The Departed.
But Al's in serious need of a hit, either critically or commercially speaking.
He's scheduled to return to theatres this fall in Righteous Kill, and while a reunion with his Heat co-star De Niro would normally be cause for considerable anticipation, the crime thriller happens to be produced and directed by the same folks responsible for 88 Minutes.
Other than that, he's considering playing the role of eccentric artist Salvador Dali in a new screen biography, which at the very worst would feature a wacky mustache to detract from any wacky hairstyle.
But neither one would likely do the trick.
To quote American Idol's Randy Jackson, "What's goin' down, dawg?"
Mr. Pacino, you've been in an extended rut before and bounced back in stuff such as Sea of Love and Scent of a Woman, so we know you've still got what it takes to return to form.
We miss the greatness.
Michael Rechtshaffen, a Canadian entertainment writer based in Los Angeles, writes Wednesdays and Sundays
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