introduction to pressure ulcers. 2 impacts of pressure ulcers pressure ulcers affect quality of life...
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Introduction to Pressure Ulcers
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.
Staging Pressure Ulcers
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
Stage 1 Pressure Ulcers
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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.
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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
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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
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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.
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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).
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Is This a Stage 1 Pressure Ulcer?
Stage 2 Pressure Ulcers
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Stage 2 Pressure Ulcer
• Partial thickness loss of dermis presenting as:
o Shallow open ulcer
o Red or pink wound bed
o Without slough
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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.
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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.
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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.
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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.
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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
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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?
Stage 3 and 4 Pressure Ulcers
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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
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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).
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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.
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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.
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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?
Unstageable Pressure Ulcers
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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)
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UnstageableNon-Removable Device
• Ulcer covered with eschar under plaster cast
• Known but not stageable because of the non-removable device
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UnstageableNon-Removable Dressing
• Known but not stageable because of the non-removable dressing
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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
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• 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
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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.
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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?
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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.
Pressure UlcerStaging Quiz
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Pressure Ulcer Quiz #1
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable -Slough or Eschar
• Unstageable - sDTI
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• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable -Slough or Eschar
• Unstageable - sDTI
Pressure Ulcer Quiz #2
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• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable -Slough or Eschar
• Unstageable - sDTI
Pressure Ulcer Quiz #3
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Pressure Ulcer Quiz #4
• Stage 1• Stage 2• Stage 3
• Stage 4• Unstageable - Slough or Eschar• Unstageable - sDTI
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• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable -Slough or Eschar
• Unstageable - sDTI
Pressure Ulcer Quiz #5
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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
Differentiating Pressure Ulcers
from OtherWounds/ Skin Conditions
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.
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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)
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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
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Arterial Ulcers
• May be result of minor trauma.
• Usual location:o Toes
o Top of foot
o Distal to medial malleolus
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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
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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
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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
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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.
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Surgical Wounds
• Healing or non-healing, open or closed surgical incisions
• Skin grafts
• Drainage sites
• Surgical flap to repair a pressure ulcer
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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.
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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.
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Characteristics of Skin Tears
• Often painful
• Part or all of epidermis (skin flap may be present)
• Shallow wounds
• Bleeding may be present
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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
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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
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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.
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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?
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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?
Wound Quiz
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Wound Quiz #1
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Wound Quiz #2
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Wound Quiz #3
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Wound Quiz #4
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Wound Quiz #5
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Wound Quiz #6
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Wound Quiz #7
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Wound Quiz #8
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Wound Quiz #9
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Wound Quiz #10
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Wound Quiz #11