Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care. APPENDIX B. Terms Abstracted from Domain Experts Reports

DOMAIN FOCUS: Pressure Ulcer Risk
Purpose for Which Term Provides Information Term
Provider Information
  • NA, RN, LPN
Patient Tracking Information  
Patient Information
  • Age
  • Gender
Pressure Ulcer
  • Assess for recurrence of pressure ulcer
  • Location of pressure ulcer
  • Stage of pressure ulcer
  • Ulcer healing
Risk Status
  • At risk for developing pressure ulcers
  • High risk for pressure ulcers
  • Risk assessment tools
  • Braden scale
  • Norton scale
  • Skin inspection
  • Periodic reassessment
Cognition/Mental Status
  • Comatose
  • Cognitive skill
  • Distracted
  • Awareness
  • Restlessness
  • Lethargy
  • Mental function
  • Altered level of consciousness
  • Depression score
  • Mental status
Can Request Help
  • Speech
  • Verbal responses
Ability to Move
  • Bed mobility
  • Bed bound
  • Chair bound
  • Transfer ability
  • Walking ability
  • Locomotion
  • Dressing ability
  • Motion of: neck, arm, hand, leg, foot
  • ADL function
  • Activities of daily living
  • Restraint use
  • Body control
  • Mobility device
  • Difficulty with repositioning
  • Impaired ability to reposition
  • Immobility
  • Spinal cord injury
  • Physical status
  • Eating ability
  • Nutritional intake
  • Oral/nutritional status
  • Oral problems
  • Oral nutritional supplements
  • Enteral feeding
  • Modular products
  • Vitamin/mineral supplements
  • Weight loss
  • BMI
  • Poor meal intake
  • Dietary intake
  • Albumin
  • Nitrogen balance
  • Nutritional status
  • Dietary intake of protein
  • Dietary intake of calories
  • Malnutrition
  • Nutrition screening
  • Nutritional assessment
Risk for Moisture Exposure
  • Toilet use
  • Personal hygiene
  • Bathing
  • Bowel incontinence
  • Bladder incontinence
  • Briefs
  • Protective padding
  • Underpads
  • Skin hydration
  • Bony prominence
Risk for Delaying Healing
  • Infections
Outcome and Risk Factor
  • History of ulcers
  • Hospital stays
Risk for Decreased Tissue Perfusion
  • Skin pliability
  • Tobacco use
  • CABG
Treatment for Pressure Ulcers
  • Ulcer care plan
  • Application of dressings
  • Clean dry dressings
  • Dressings that keep ulcer bed continuously moist
  • Protective dressings
  • Cleanse wound
  • Mild cleansing agent
  • Whirlpool treatment
  • Wet to dry dressings
  • Debridement
  • Topical debriding agents
  • Autolytic debridement
  • Enzymatic debridement
  • Mechanical debridement
  • Wound irrigation
  • Foam
  • Gel
  • Growth factors
  • Hormones
  • Hyperbaric oxygen
  • Infrared ultraviolet
  • Hydrotherapy
  • Normal saline
  • Topical agents
  • Topical amioglycoside treatment
  • Topical antibiotics
  • Topical treatment with iodine containing agents
  • Avoid massage over bony prominences
  • Moisturizers
  • Lubricants (corn starch and cream)
  • Electrical stimulation therapy
  • Low energy laser irradiation
  • Assisted oral feeding
  • Oral supplements
  • Devices that totally relieve pressure
  • Distribution of weight
  • Proper postural alignment
  • Characteristics of support surfaces
  • Dynamic support surface
  • Low air loss bed
  • Pressure relief
  • Pressure reducing beds
  • Pressure reducing mattresses
  • Pressure reducing overlays
  • Maintain position in bed or chair
  • Nutritional management
  • Aggressive nutritional interventions
  • Air fluidized beds
  • Plan of nutritional support
  • Patient education
  • Repositioning schedule
  • Surgical flap
  • Postoperative viability of the surgical site
  • Evaluate adequacy of treatment
Condition Factors
  • Radiation treatment
  • Friction injuries
  • Bed linen to move
  • Lifting devices
  • Minimize force and friction
  • Positioning devices
  • Transferring support
  • Turning techniques


DOMAIN FOCUS: Chronic Pain
Purpose for Which Term Provides Information Terms
Risk Factors for Chronic Pain in Long-Term Care Facilities
  • Presence of diagnoses known to be painful: osteoarthritis, low back pain, fibromyalgia, spinal stenosis, post-herpetic neuralgia, peripheral neuropathy, myofascial pain syndromes, vasogenic claudication, phantom limb pain, headaches, vasculitic pain syndromes, osteoporosis with fractures, cancer, contractures, peripheral vascular disease, pheumatoid arthritis
Risk of Unrecognized and Thus Untreated Pain
  • Dementia
  • Delirium
  • Pain map
  • Drawing
  • Description
Intensity or Severity of Pain
  • Numeric estimate (0-100)
  • Verbal descriptors scale: no pain, moderate, severe, excruciating, worst pain possible, most intense pain imaginable
  • Faces pain scale
  • Terms within McGill pain questionnaire
  • Intermittent, continuous, lasting minutes or hours
  • When starts, what started it, what makes it better, what makes it worse
Pain Behaviors
  • Facial (wrinkled forehead, tightly closed eyes, grimacing, frowning)
  • Nonverbal behavior (bracing, rubbing, guarding)
  • Vocalizations (crying, yelling, groaning, moaning)
Nonverbal Indicators of Discomfort
  • Aggressive, crying, fearful, negative vocalization, noisy respirations, pacing, repetitive, restlessness, rocking, confusion irritability, increased activity, withdrawal, tense, calling out, grunting, knees pulled up.
  • Other changes in usual activities or behavior patterns/routines.
Impact of Pain on Quality of Life Outcomes
  • Physical function, sleep, appetite, interpersonal relationship/interactions with others, mood (anxiety, depression), mental status (ability to think clearly/ concentration/confusion), energy/fatigue
  • Pain intensity monitoring
  • Appropriate use of medications
  • Appropriate use of non-pharmacologic interventions


DOMAIN FOCUS: Urinary Incontinence
Purpose for Which Term Provides Information Terms
Target History
Mental Status
Characteristics of Voiding and Non-Invasive Bladder Diagnosis
Ability to Toilet
Prior Treatment for Incontinence
Importance of Problem to Resident
  • MDS recall scale, MDS item B3, or Cognitive performance scale
  • derived from MDS items
  • Frequency of incontinence
  • Status of incontinence: day and night
  • Symptoms on urination
  • Symptoms to distinguish between urge incontinence (short interval between sensation to void and bladder contraction) and stress incontinence (urine loss during physical movements)
  • Mobility problems on MDS and provider notes
Targeted Physical
  • Rectal exam to exclude fecal impaction
  • Skin exam to evaluate skin problems associated with urinary incontinence
  • Genital system exam to identify physical abnormalities that may explain incontinence (e.g., pelvic prolapse)
Factors Associated with UI
  • Lab reports
  • Primary care provider notes
Toileting Responsiveness Assessments
  • How often person voids when prompted on a routine basis
  • Voiding record
  • Non-invasive diagnoses of bladder function
Urodynamic Analyses of Bladder Functioning  
  • Prompted toileting
  • Prompted voiding
  • Scheduled toileting
  • Timed voiding

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