Wound Measuring And Staging Inservice

St. John’s Hyperbaric and Wound Treatment Center

Lisa Hezel, RN WCC

Measuring and Staging Wounds

Measuring and Staging Wounds

Chronic refractory osteomyelitis of right heel

Plantar surface of the footCaused by pressure from a poorly fitting

shoe, patient is diabeticHow do we measure this wound?How do we stage this wound?

Measuring and Staging Wounds

Official Statement concerning this in-service!! This staging system was developed by the

NPUAP(National Pressure Ulcer Advisory Panel) and classifies only pressure ulcers based on anatomical depth of soft tissue damage.

Another system for diabetic foot ulcers only is called the Wagner system and is usually utilized by podiatrists. We will not cover that today.

Measuring and Staging Wounds

STAGE 1- An observable pressure related alteration of intact skin whose indicators may include one or more of the following: skin temperature (warmth or coolness) tissue consistency (firm or boggy) sensation (pain/itching) appears as defined area of persistent redness

in lightly pigmented skin, whereas in darker skin tones, this ulcer may appear with persistent red, blue or purple hues.

Measuring and Staging Wounds

Examples of Stage 1 Pressure Ulcers

Measuring and Staging Wounds

Stage 2-Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. Pink Partial Painful NEVER has slough,eschar or undermining

Measuring and Staging Wounds

Examples of Stage 2 Pressure Ulcers

Measuring and Staging Wounds

Stage 3- Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to but not through, underlying fascia.

The ulcer presents clinically as deep crater with or without undermining of adjacent tissue.

Measuring and Staging Wounds

Examples of Stage 3 pressure wounds.

Measuring and Staging Wounds

Stage IV—Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (ie. Tendon, joint capsule) Undermining and sinus tracts may be

associated w/ stage IV ulcers Can differentiate from stage III ulcers because it

will go PAST the Fascia

Measuring and Staging Wounds

Example of a stage IV woundPast the skin, subcutaneous level and goes to the

calcaneous bone

Measuring and Staging Wounds

Unstageable Pressure Ulcer—A pressure ulcer cannot be accurately staged until the deepest viable tissue layer is visible; this means that wounds covered w/ eschar &/or slough should be documented as unstageable.

EXCEPTION: In Longterm Care, the MDS form states that if a wound is covered w/ enough eschar/necrotic tissue which prevents adequate staging, then the code for that form will be a Stage IV pressure ulcer.

Measuring and Staging Wounds

Examples of Unstageable Pressure Ulcers.

Measuring and Staging Wounds

Deep Tissue Injury—describes a variation of pressure ulcers that appear initially as bruised or dark tissue. The location is the muscle bed or subcutaneous fat. The skin is usually intact at time of initial assessment. No Recognized diagnostic tools can identify pressure

related deep tissue injury under intact skin, therefore you must rely on visual inspection and palpation.

The area may be painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Measuring and Staging Wounds

Proposed Etiology of DTI— Pressure to the skin and soft tissue and

ischemia Muscle injury associated with a decrease in

nutrient supply Injury or damage to the fascia from shearing

injury or torsion of the perforating vessels

Measuring and Staging Wounds

Deep Tissue Injury--The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

DTI over a heel may look like a bruise or blood blister

Measuring and Staging Wounds

Classification Of Wounds Non pressure related wounds are classified as

either Partial or Full thickness. Venous Stasis Ulcers Skin Tears Burns

Measuring and Staging Wounds

Partial Thickness—destruction of the epidermis and dermis—You will never see slough in a partial thickness wound!

Measuring and Staging Wounds

Full Thickness—Destruction of epidermis and dermis, subcutaneous and or deeper.

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962006000600002&tlng=en&lng=en&nrm=iso

Measuring and Staging Wounds

Burns Superficial Superficial partial thickness Deep Partial Thickness Full Thickness

Measuring and Staging Wounds

Linear Style for Measuring wounds Length X Width X Depth Wound edge to wound edge in a straight line Consider the wound as a face of a clock—12

points to the patient’s head and 6 to the patient’s feet.

Measuring and Staging Wounds

Measuring on the foot using the clock system—Can be tricky! Just pretend your patient is a ballerina with her toes pointed and the heel will be 12:00 and the toes will be 6:00.

Measuring and Staging Wounds

To obtain measurements: Measure the longest from 12-6 on the clock and

3-9 on the clock. This keeps the measurements consistent from

week to week. When in doubt: draw a picture of what you

measured to make it easier for the next nurse!

Measuring and Staging Wounds

Depth—Distance from visible surface to the deepest area. Cotton tip applicator to the deepest portion of

the wound. Grasp the applicator w/ finger and thumb at the

point corresponding to the wounds margin. Withdraw from wound while maintaining

position of finger and thumb on the applicator. Measure from tip of applicator to position

against a centimeter ruler.

Measuring and Staging Wounds

Tunneling and Undermining—measure and document depth and direction. Use cotton tip applicator and gently probe around wound

edges in clockwise direction. Once tunneling/undermining have been identified, insert

applicator into that area. Grasp the applicator where it meets the wound edge w/

thumb and forefinger. Withdraw the applicator while maintaining the position of

the thumb and forefinger. Measure from the tip of the applicator to the position. Document based on a time on the clock ie. Tunneling at 1

o’clock measures 2 cm.