Transcript HOW - Wound/Ostomy Related Documents

??? HOW ???

The staging system currently
recommended by AHRQ (AHCPR),
NPUAP and WOCN (and accepted
by Medicare) is a six-stage system
based on the tissue layers
involved
LOOK FAMILIAR?
NOW YOU KNOW
WHY THERE WAS
A REASON YOU
MEMORISED THIS
Stage I

Defined area of non-blanchable
erythema of INTACT skin (vs.
reactive hyperemia) usually over
a bony prominence. Pigmented
skin may not have visible
blanching; its color may differ from
surrounding area.The area may be
painful, firm, soft (boggy) warmer
or cooler than adjacent tissue.
(NOT eschar)
Take home
Words?
Intact
Non-blanchable
Non-necrotic
Boggy
And think…..?pressure point?
7/21/2015
Reactive Hyperemia

is the red skin color that is normally
observed once pressure to an area has
been relieved. This type of hyperemia is
blanchable and will resolve in
approximately 1/2 to 3/4 the amount of
time that the area was exposed to
pressure. (Increased blood supply to
clear away byproducts of ischemia) e.g.
a patient who is repositioned Q 2H may
experience this over a bony prominence
for as long as 11/2 hours following the
position change.
Reactive Hyperemia

Stand up: look at your fingers,
your neighbor’s crossed ankles ,
a leaned-upon elbow, and if you
ask very politely, posterior thigh
at chair edge

This is a normal process and
should not be misclassified as a
Stage I pressure ulcer.
Deep Tissue Injury



Manifested as deep red, maroon,
purple tissue or blood-filled blister.
Epidermis may or may not be
intact and usually sloughs off.
Usually results from
pressure/shear
NOT to be confused with Stage I
CAUTION





Be careful about charting “red
sacrum” : Is it
Hyperemia?
Stage I?
Scar?
Deep Tissue Injury?