OASIS-C Integument Assessment: Not for Wimps! Part I: Pressure Ulcers Presented by: Rhonda Will, RN, BS, COS-C, HCS-D Assistant Director, OASIS Competency Institute 243 King Street, Suite 246 Northampton, MA 01060 413-584-5300 Fax: 413-584-0220 www.fazzi.com
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OASIS-C Integument Assessment: Not for Wimps! Part I: Pressure Ulcers
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.
4 Stages + Suspected Deep Tissue Injury + Unstageable
• Intact skin with non‐blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Further description:The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk).
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum‐filled blister.
Further description:Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
Full thickness tissue loss. Subcutaneous fat maybe visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
CMS modifies the NPUAP reference to “directly palpable” in a stage IV pressure description. For OASIS purposes, to classify a pressure ulcer as a stage IV, exposed bone/tendon must be “visible” and not “directly palpable”.
• Purple or maroon localized area of discolored intact skin OR a blood filled blister due to damage of underlying soft tissue from pressure and/or shear.
• The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Further description:Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapidly exposing additional layers of tissue even with optimal treatment.
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Further description:Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.
Patient 3 At Discharge, the stage II pressure ulcer that was open at SOC has healed. There is a different stage II pressure ulcer open in another location. The stage III pressure ulcer remains open and the other stage III pressure ulcer remains closed.
Patient 4 At Recertification, the stage II pressure ulcer that was open at SOC has fully re‐epithelialized. Another stage II PU is open in a different location. The stage III PU now has bone exposed and the other stage III PU remains closed.
Patient 5 At SOC, there is 1 pressure ulcer on the left heel covered with eschar and 1 blood filled blister on the right heel from pressure after many days of bed rest. There is a stage III pressure ulcer which closed in the hospital and remains closed.
Patient 5 At Recertification, the pressure ulcer on the left heel remains covered with eschar. The blood‐filled blister on the right heel has broken open and is now a stage III. The stage III pressure ulcer which closed in the hospital remains closed.
Patient 6 is bedbound. At SOC there is a skin graft on a stage III pressure ulcer with orders not to remove the pressure dressing until the physician's visit. There is a deep red, warm and boggy area noted on the right heel.
Patient 6 At Discharge, the skin graft on the stage III pressure ulcer has healed with some contracture and discoloration of the graft site and the deep red, warm and boggy area noted on the right heel is resolved.
Patient 7 At Recertification, there is no evidence of a stage I pressure ulcer on the right heel. The stage I pressure ulcer on the left heel is now a stage II.
M1310, M1312, M1314 ‐ Unhealed Stage III or IV Pressure Ulcer with Largest Surface Dimension
SOC/ROC/DC
Time Points WOCN Guidelines NPUAP Staging
Consider all stage III and IV pressure ulcers from M1308 Col.1 row b (stage III), row c (stage IV), and row d.2 (unstageablecovered w/ slough or eschar).
Depth does not include the depth of any tunneling.
Stage II pressure ulcers that close/heal/fully epithelialize are not reportable on OASIS and therefore will not be “newly epithelialized” for data collection.
Stage II pressure ulcers do not granulate.
Stage II pressure ulcers (includes serum filled blister) can only be “not healing” for data collection.
M1324 Stage Most Problematic (Observable) Pressure Ulcer SOC/ROC/FU/DC
Time Points WOCN Guidelines NPUAP Staging
Upon inspection, the patient has 1 pressure ulcer on the left heel that is covered with eschar. There is 1 stage III pressure ulcer on his sacrum. Granulation tissue is present in the wound bed with areas of slough scattered over 10% of the wound bed.
• Staging an ulcer requires seeing the wound base.
• In a multi pressure ulcer situation, consider an ulcer that is observable over one that is not.