Transcript Staging the Pressure Ulcer

Introduction to
Pressure Ulcers
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
2
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
3
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
4
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
5
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
6
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
7
Pressure Ulcer Assessment
• Staging
o 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
8
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 pressurebearing areas.
o Use visual inspection and palpation.
o Ensure a comprehensive assessment.
Introduction to Pressure Ulcers
9
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
10
Staging
Pressure Ulcers
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
12
Stage 1 Pressure Ulcers
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
14
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
15
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
16
Assessing Stage 1 Pressure Ulcers3
• Search for other areas of skin that differ
from surrounding tissue.
o Painful
o Firm
o Soft
o Color
change
o Warmer/ cooler
• 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
17
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
18
Is This a Stage 1 Pressure Ulcer?
Introduction to Pressure Ulcers
19
Stage 2 Pressure Ulcers
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
21
Stage 2 Pressure Ulcer, Cont.
• May also present
as an intact or open/
ruptured blister
Introduction to Pressure Ulcers
22
Assessing Stage 2
Pressure Ulcers
• Perform a head-to-toe, full body skin
assessment.
• Focus on bony prominences and pressurebearing areas.
Introduction to Pressure Ulcers
23
Assessing Stage 2
Pressure 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
24
Differentiating
Stage 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
25
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
26
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
27
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
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
Stage 3 and 4
Pressure Ulcers
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
32
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
33
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
34
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
35
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
36
Unstageable Pressure
Ulcers
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
38
Unstageable
Non-Removable Device
• Ulcer covered with eschar under plaster cast
• Known but not stageable because of the nonremovable device
Introduction to Pressure Ulcers
39
Unstageable
Non-Removable Dressing
• Known but not stageable because of
the non-removable dressing
Introduction to Pressure Ulcers
40
Unstageable
Slough and/or Eschar
• Known but not stageable due to coverage of
wound bed by slough and/or eschar
• Full thickness tissue
loss
• 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
41
Unstageable
Suspected Deep Tissue Injury
• 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
Introduction to Pressure Ulcers
42
Unstageable
Suspected 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
43
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
44
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
45
Pressure Ulcer
Staging Quiz
Pressure Ulcer Quiz #1
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers
47
Pressure Ulcer Quiz #2
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers
48
Pressure Ulcer Quiz #3
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers
49
Pressure Ulcer Quiz #4
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable - Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers
50
Pressure Ulcer Quiz #5
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers
51
Pressure Ulcer Quiz #6
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers
52
Pressure Ulcer Quiz #7
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers
53
Pressure Ulcer Quiz #8
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable - Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers
54
Pressure Ulcer Quiz #9
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable - Slough or Eschar
• Unstageable - sDTI
Introduction to Pressure Ulcers
55
Differentiating
Pressure Ulcers
from Other
Wounds/ Skin Conditions
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
57
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
58
Venous Ulcers
• May be result of minor trauma.
• Usual location is lower
leg area or medial
or lateral malleolus.
• Characterized by:
o Irregular wound edges
o Hemosiderin staining
o Leg edema
Introduction to Pressure Ulcers
59
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
60
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
61
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
62
Characteristics of
Diabetic 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
63
Open Lesions Other
than 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
64
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
65
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
66
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
67
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
68
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
69
Characteristics of MoistureAssociated 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
70
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
71
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
72
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?
Introduction to Pressure Ulcers
73
Wound Quiz
Wound Quiz #1
Introduction to Pressure Ulcers
75
Wound Quiz #2
Introduction to Pressure Ulcers
76
Wound Quiz #3
Introduction to Pressure Ulcers
77
Wound Quiz #4
Introduction to Pressure Ulcers
78
Wound Quiz #5
Introduction to Pressure Ulcers
79
Wound Quiz #6
Introduction to Pressure Ulcers
80
Wound Quiz #7
Introduction to Pressure Ulcers
81
Wound Quiz #8
Introduction to Pressure Ulcers
82
Wound Quiz #9
Introduction to Pressure Ulcers
83
Wound Quiz #10
Introduction to Pressure Ulcers
84
Wound Quiz #11
Introduction to Pressure Ulcers
85