Introduction to Pressure Ulcers. 2 Impacts of Pressure Ulcers Pressure ulcers affect quality of life for patients: Limit activity. Are painful. Require.

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.


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


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.


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.


Pressure Ulcer Risk Factors

• Immobility, decreased functional ability

• Co-morbid conditions (ESRD, thyroid)

• Diabetes

• Drugs such as steroids

• Impaired diffuse or localized blood flow


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


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.


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.


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


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


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.


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


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


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.


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).


Is This a Stage 1 Pressure Ulcer?

Stage 2 Pressure Ulcers



• Partial thickness loss of dermis presenting as:

o Shallow open ulcer

o Red or pink wound bed

o Without slough


Stage 2 Pressure Ulcer, Cont.

• May also present as an intact or open/ ruptured blister


Assessing Stage 2 Pressure Ulcers

• Perform a head-to-toe, full body skin assessment.

• Focus on bony prominences and pressure-bearing areas.


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.


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.


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.


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



1. What steps should you take to assess this?

2. Is this a Stage 2 pressure ulcer?









Stage 3 and 4 Pressure Ulcers



• 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



• 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).


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.


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.


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


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)


UnstageableNon-Removable Device

• Ulcer covered with eschar under plaster cast

• Known but not stageable because of the non-removable device


UnstageableNon-Removable Dressing

• Known but not stageable because of the non-removable dressing


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


• 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


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.


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?


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


Pressure Ulcer Quiz #1

• Stage 1

• Stage 2

• Stage 3

• Stage 4

• Unstageable -Slough or Eschar

• Unstageable - sDTI


• Stage 1

• Stage 2

• Stage 3

• Stage 4





• Stage 1

• Stage 2

• Stage 3

• Stage 4






• Stage 1• Stage 2• Stage 3

• Stage 4• Unstageable - Slough or Eschar• Unstageable - sDTI


• Stage 1

• Stage 2

• Stage 3

• Stage 4






• Stage 1

• Stage 2

• Stage 3

• Stage 4





• Stage 1

• Stage 2

• Stage 3

• Stage 4

• Unstageable - Slough or Eschar










Differentiating Pressure Ulcers

from OtherWounds/ 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.


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)


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


Arterial Ulcers

• May be result of minor trauma.

• Usual location:o Toes

o Top of foot

o Distal to medial malleolus


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


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


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


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.


Surgical Wounds

• Healing or non-healing, open or closed surgical incisions

• Skin grafts

• Drainage sites

• Surgical flap to repair a pressure ulcer


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.


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.


Characteristics of Skin Tears

• Often painful

• Part or all of epidermis (skin flap may be present)

• Shallow wounds

• Bleeding may be present


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


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


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.


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?


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


Wound Quiz #1


Wound Quiz #2


Wound Quiz #3


Wound Quiz #4


Wound Quiz #5


Wound Quiz #6


Wound Quiz #7


Wound Quiz #8


Wound Quiz #9


Wound Quiz #10


Wound Quiz #11

Introduction to Pressure Ulcers. 2 Impacts of Pressure Ulcers Pressure ulcers affect quality of life for patients: Limit activity. Are painful. Require.

Documents

presence of pressure

result of pressure

pressure ulcer stages

pressure ulcer intact

permission slide

body skin assessment

assessment period

comprehensive assessment