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Introduction to Pressure Ulcers 2
Impacts of Pressure Ulcers
Pressure ulcers affect quality of life for patients:•Limit activity.
•Are painful.
•Require time-consuming treatments and dressing changes.
•Can pose a risk of infection and sepsis.
Introduction to Pressure Ulcers 3
Presentation Addresses:
• What is a pressure ulcer (the 2007 definition)
• Risk factors
• General guidelines for assessment
• Staging pressure ulcers
• Differentiating pressure ulcers from other wounds/ skin conditions
Introduction to Pressure Ulcers 4
Objectives
• Define pressure ulcer.
• Identify key components of pressure ulcer assessment.
• Describe major characteristics of the pressure ulcer stages.
• Differentiate pressure ulcers from other wounds/ skin conditions.
Introduction to Pressure Ulcers 5
CMS Pressure Ulcer Definition
CMS has adapted the NPUAP 2007 definition for a pressure ulcer:
A pressure ulcer is a 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.
Introduction to Pressure Ulcers 6
Pressure Ulcer Risk Factors
• Immobility, decreased functional ability
• Co-morbid conditions (ESRD, thyroid)
• Diabetes
• Drugs such as steroids
• Impaired diffuse or localized blood flow
Introduction to Pressure Ulcers 7
Pressure Ulcer Risk Factors, Cont.
• Exposure to moisture, urinary and fecal incontinence
• Under-nutrition, malnutrition, hydration deficits
• Patient refusal of care and treatment
• Cognitive impairment
• Healed pressure ulcer that has closed
Introduction to Pressure Ulcers 8
Pressure Ulcer Assessment
• Stagingo Categorizing pressure ulcers in terms of depth
of tissue loss
o Stages 1-4 and Unstageable
• Distinguishing pressure ulcers from wounds/skin conditions o Imperative to differentiate the etiology for
proper treatment and management of wound.
Introduction to Pressure Ulcers 9
General Assessment Guidelines
• Review the medical record.
• Examine the patient.
o Perform a head-to-toe, full body skin assessment.
o Focus on bony prominences and pressure-bearing areas.
o Use visual inspection and palpation.
o Ensure a comprehensive assessment.
Introduction to Pressure Ulcers 10
General Assessment Guidelines, Cont.
• Consult with direct care staff on all shifts.
• Assess for the presence of pressure ulcers during assessment period.
• Document assessment findings in patient’s medical record.
Introduction to Pressure Ulcers 12
Staging Definitions
• CMS has adapted the 2007 NPUAP definitions for categories of staging.
• Resource: www.npuap.org
• Free diagrams of ulcer stages can be downloaded for educational use.
Reproduced with permission
Introduction to Pressure Ulcers 14
Stage 1 Pressure Ulcer
• Intact skin with non-blanchable redness of a localized area, usually over a bony prominence.
• Darkly pigmented skin may not have visible blanching.
• Color may differ from the surrounding area.
Introduction to Pressure Ulcers 15
Assessing Stage 1 Pressure Ulcers
• Perform a head-to-toe, full body skin assessment.
• Focus on bony prominences and pressure-bearing areas:o Sacrum
o Heels
o Buttocks
o Ankles
Introduction to Pressure Ulcers 16
Assessing Stage 1 Pressure Ulcers2
• Consider where patient spends time.
• Check any reddened areas for ability to blanch.
o Firmly press finger into tissue, then remove.
o Non-blanchable: no loss of skin color or pressure-induced pallor at the compressed site
Introduction to Pressure Ulcers 17
Assessing Stage 1 Pressure Ulcers3
• Search for other areas of skin that differ from surrounding tissue.
o Painful
o Firm
o Soft
o Warmer/ cooler
o Color change
• Assessment to determine staging should be comprehensive.
• Stage 1 ulcers may be difficult to detect in individuals with dark skin tones.
Introduction to Pressure Ulcers 18
Differentiating Stage 1 Pressure Ulcers
• Differentiate Stage 1 pressure ulcer and suspected deep tissue injuries (sDTIs).
• Differentiate Stage 1 pressure ulcers and moisture-associated skin damage (MASD).
Introduction to Pressure Ulcers 21
Stage 2 Pressure Ulcer
• Partial thickness loss of dermis presenting as:
o Shallow open ulcer
o Red or pink wound bed
o Without slough
Introduction to Pressure Ulcers 22
Stage 2 Pressure Ulcer, Cont.
• May also present as an intact or open/ ruptured blister
Introduction to Pressure Ulcers 23
Assessing Stage 2 Pressure Ulcers
• Perform a head-to-toe, full body skin assessment.
• Focus on bony prominences and pressure-bearing areas.
Introduction to Pressure Ulcers 24
Assessing Stage 2Pressure Ulcers, Cont.
• Examine the area adjacent to or surrounding any intact blister for evidence of tissue damage.
o Color change
o Tenderness
o Bogginess or firmness
o Warmth or coolness
• If the surrounding or adjacent soft tissue does NOT have the evidence of tissue damage, it is a Stage 2 pressure ulcer.
Introduction to Pressure Ulcers 25
DifferentiatingStage 2 Pressure Ulcers
• Confirm that the wound being assessed is primarily related to pressure.
o Rule out other conditions.
o Do not identify a wound as a pressure ulcer if pressure is not the primary cause.
Introduction to Pressure Ulcers 26
Differentiating Stage 2 Pressure Ulcers2
• Differentiate Stage 2 pressure ulcers and deep tissue injuries.
• Stage 2 ulcers will generally lack the surrounding characteristics (color change, tenderness, bogginess, etc.) found with a deep tissue injury.
Introduction to Pressure Ulcers 27
Differentiating Stage 2 Pressure Ulcers3
• Do not identify the following as pressure ulcers:
o Skin tears
o Tape burns
o Moisture associated Skin Damage from incontinence
o Excoriation
Introduction to Pressure Ulcers 28
Is This a Stage 2 Pressure Ulcer?
1. What steps should you take to assess this?
2. Is this a Stage 2 pressure ulcer?
Introduction to Pressure Ulcers 29
Is This a Stage 2 Pressure Ulcer?
1. What steps should you take to assess this?
2. Is this a Stage 2 pressure ulcer?
Introduction to Pressure Ulcers 30
Is This a Stage 2 Pressure Ulcer?
1. What steps should you take to assess this?
2. Is this a Stage 2 pressure ulcer?
Introduction to Pressure Ulcers 32
Stage 3 Pressure Ulcer
• Full thickness tissue loss
• Subcutaneous fat may be visible but bone, tendon or muscle is not exposed.
• Slough may be present but does not obscure the depth of tissue loss.
• May include undermining and tunneling
Introduction to Pressure Ulcers 33
Stage 4 Pressure Ulcer
• Full thickness tissue loss with exposed bone, tendon or muscle.
• Slough or eschar may be present on some parts of the wound bed.
• Often includes undermining and tunneling.
• Depth varies by anatomical location (bridge of nose, ear, occiput, and malleous ulcers can be shallow).
Introduction to Pressure Ulcers 34
Distinguishing Stage 3 and 4 Pressure Ulcers
• Stage 3: Bone, tendon or muscle is not visible or palpable.
• Stage 4: Bone, tendon or muscle is visible or palpable.
Introduction to Pressure Ulcers 35
Reverse Staging
• Do not reverse stage.
o Example: Over time, a Stage 4 pressure ulcer has been healing. Previously, reverse staging was permitted. Once the pressure ulcer reached a depth consistent with Stage 2 pressure ulcers, could be identified as Stage 2.
o Currently, it is required that it continue to be documented as a Stage 4 until completely healed.
Introduction to Pressure Ulcers 36
Scenario: Staging the Pressure Ulcer
• A pressure ulcer described as a Stage 2 was documented in the patient’s medical record at the time of admission.
• On a later assessment, the wound is noted to be a full thickness ulcer with no exposure of bone, tendon or muscle.
• What is the stage of the ulcer now?
Introduction to Pressure Ulcers 38
Unstageable Pressure Ulcers
• Three types to differentiate:
o Unstageable due to Non-Removable Device or Dressing
o Unstageable due to Slough and/or Eschar
o Unstageable due to Suspected Deep Tissue Injury (sDTI)
Introduction to Pressure Ulcers 39
UnstageableNon-Removable Device
• Ulcer covered with eschar under plaster cast
• Known but not stageable because of the non-removable device
Introduction to Pressure Ulcers 40
UnstageableNon-Removable Dressing
• Known but not stageable because of the non-removable dressing
Introduction to Pressure Ulcers 41
UnstageableSlough and/or Eschar
• Known but not stageable due to coverage of wound bed by slough and/or eschar
• Full thickness tissueloss
• Base of ulcer covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed
Introduction to Pressure Ulcers 42
• Related to damage of underlying soft tissue from pressure and/or shear
• Deep tissue injuries can indicate severe damage. Identification and management imperative.
• Localized area of discolored (darker than surrounding tissue), intact skin
UnstageableSuspected Deep Tissue Injury
Introduction to Pressure Ulcers 43
UnstageableSuspected Deep Tissue Injury
• Area of discoloration may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
• Deep tissue injury may be difficult to detect in individuals with dark skin tones.
• Identify as Unstageable due to sDTI when wound related to pressure presents with intact blister and surrounding or adjacent soft tissue has characteristics of deep tissue injury.
Introduction to Pressure Ulcers 44
Scenario: Staging the Pressure Ulcer
• Ms. James was admitted with one small Stage 2 pressure ulcer.
• Despite treatment, it is not improving.
• The wound bed is covered with slough.
• What is the stage of the ulcer now?
Introduction to Pressure Ulcers 45
A Final Word
• Quality health care begins with prevention of and assessment for pressure ulcers.
• Clearly document assessment findings in the patient’s medical record.
• Track and document appropriate wound care planning and management.
Introduction to Pressure Ulcers 47
Pressure Ulcer Quiz #1
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable -Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers 48
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable -Slough or Eschar
• Unstageable - sDTI
Pressure Ulcer Quiz #2
Introduction to Pressure Ulcers 49
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable -Slough or Eschar
• Unstageable - sDTI
Pressure Ulcer Quiz #3
Introduction to Pressure Ulcers 50
Pressure Ulcer Quiz #4
• Stage 1• Stage 2• Stage 3
• Stage 4• Unstageable - Slough or Eschar• Unstageable - sDTI
Introduction to Pressure Ulcers 51
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable -Slough or Eschar
• Unstageable - sDTI
Pressure Ulcer Quiz #5
Introduction to Pressure Ulcers 52
Pressure Ulcer Quiz #6
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable -Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers 53
Pressure Ulcer Quiz #7
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable - Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers 54
Pressure Ulcer Quiz #8
• Stage 1• Stage 2• Stage 3
• Stage 4• Unstageable - Slough or Eschar• Unstageable - sDTI
Introduction to Pressure Ulcers 55
Pressure Ulcer Quiz #9
• Stage 1• Stage 2• Stage 3
• Stage 4• Unstageable - Slough or Eschar• Unstageable - sDTI
Introduction to Pressure Ulcers 57
Importance of Wound Differentiation
• There are a variety of other wound types in addition to pressure ulcers.
• Differentiating wounds requires knowledge, experience, patient history/ events, and interdisciplinary collaboration.
• A comprehensive assessment is needed.
• Differentiating the etiology of the wound is essential to determine and direct the proper treatment and management of the wound.
Introduction to Pressure Ulcers 58
Wounds and Skin Conditions
• Venous and Arterial Ulcers
• Diabetic Foot Ulcers
• Open Lesions Other than Ulcers, Rashes, Cuts
• Surgical Wounds
• Burns
• Skin Tears
• Moisture-Associated Skin Damage (MASD)
Introduction to Pressure Ulcers 59
Venous Ulcers
• May be result of minor trauma.
• Usual location is lower leg area or medialor lateral malleolus.
• Characterized by:o Irregular wound edgeso Hemosiderin stainingo Leg edema
Introduction to Pressure Ulcers 60
Arterial Ulcers
• May be result of minor trauma.
• Usual location:o Toes
o Top of foot
o Distal to medial malleolus
Introduction to Pressure Ulcers 61
Characteristics of Arterial Ulcers
• Necrotic tissue or pale pink wound bed
• Diminished or absent pulses
• Trophic skin changes:o Dry skin
o Loss of hair
o Brittle nails
o Muscle atrophy
Introduction to Pressure Ulcers 62
Diabetic Foot Ulcers
• Caused by the neuropathic and small blood vessel complications of diabetes.
• Usual location: Over plantar (bottom) surface of foot on load bearing areas
Introduction to Pressure Ulcers 63
Characteristics ofDiabetic Foot Ulcers
• Usually deep, with necrotic tissue, moderate amounts of exudate and calloused wound edges
• Very regular in shape; wound edges are even, with a punched-out appearance
• Even though patient has neuropathy, may have pain
Introduction to Pressure Ulcers 64
Open Lesions Otherthan Ulcers, Rashes, Cuts
• Typically, skin ulcers that develop as a result of diseases and conditions such as syphilis and cancer.
• Patient history is helpful to identify wound etiology.
• Type of skin condition will determine location.
Introduction to Pressure Ulcers 65
Surgical Wounds
• Healing or non-healing, open or closed surgical incisions
• Skin grafts
• Drainage sites
• Surgical flap to repair a pressure ulcer
Introduction to Pressure Ulcers 66
Burns
• Skin and tissue injury caused by heat or chemicals.
• Patient history of events is helpful to differentiate etiology and type of burn.
• May be in any stage of healing.
Introduction to Pressure Ulcers 67
Skin Tears
• Are acute traumatic wounds.
• May occur as a result of shear, friction or trauma to the skin.
• The epidermis separates from the dermis.
• Usually occur on the extremities of older adults.
Introduction to Pressure Ulcers 68
Characteristics of Skin Tears
• Often painful
• Part or all of epidermis (skin flap may be present)
• Shallow wounds
• Bleeding may be present
Introduction to Pressure Ulcers 69
Moisture-Associated Skin Damage
• Occurs with sustained exposure to moisture
• Several etiologies associated with MASD
o Example: urinary or fecal incontinence
• Location of MASD associated with its etiology
Introduction to Pressure Ulcers 70
Characteristics of Moisture-Associated Skin Damage
• Inflammation and erosion of the skin
• Very diffuse, with reddened, superficial area(s)
• Initially superficial but further damage may result from factors such as pressure
• May have superimposed fungal infection (on top of MASD)
• No necrotic tissue
Introduction to Pressure Ulcers 71
Assessing Wounds/ Skin Conditions
• Review the medical record.o Skin care flow sheet or other skin tracking form.o Treatment records and orders for documented
treatments.
• Speak with direct care staff and treatment nurse.o Confirm conclusions from medical record review.
• Examine the patient.o Determine if ulcers, wounds, or skin problems are
present.o Observe skin treatments.
Introduction to Pressure Ulcers 72
Scenario #1
What Type of Skin Condition?
• A patient has diabetes mellitus.
• He presents with an ulcer on the heel that is due to pressure.
• Is this a pressure ulcer or another skin condition?
Introduction to Pressure Ulcers 73
Scenario #2
What Type of Skin Condition?
• A patient is readmitted from the hospital after flap surgery to repair a sacral pressure ulcer.
• Is this a pressure ulcer or another skin condition?