Pressure Ulcers: Staging and Risk Assessment

1. Pressure Ulcers: Staging and Risk Assessment Keri Holmes-Maybank, MD Medical University of South Carolina

2. Learning objectives • Residents will be able to stage pressure ulcers in hospitalized patients. • Residents will recognize the relationship between pressure ulcer healing and nutrition. • Residents will recognize the importance of pressure ulcer prevention.  • Residents will recognize the Braden Scale as a tool to identify patients at risk for pressure ulcer formation.

3. Key Messages • In hospital pressure ulcer formation is on the rise. • Pressure ulcers lead to increased mortality, hospital cost, and length of stay. • Staging of pressure ulcers is standardized by the National Pressure Ulcer Advisory Board. • 99% of deep tissue injuries lead to stage III or Stage IV ulcers.

4. Pressure Ulcers

5. Pressure Ulcers • 2.5 million hospitalized patients/yr • 60,000 die/yr from pressure ulcer complications • 1 in 25 if pressure ulcer reason for admit • 1 in 8 if pressure ulcer secondary diagnosis • 10-18% acute care patients • 0.4-38% acute care new ulcers

6. Pressure Ulcers • 80% increase pressure ulcer related hospitalizations 1993-2006 • Length of Stay 13-14 days (average LOS 5 days) • $9.2-15.6 billion in 2008 • 1999-2002 awards avg $13.5 million • $312 million in one case

7. Impact on Patients • Reduces quality of life • Interfere with basic activities of daily living • Increased pain • Decrease functional ability • Infection – OM and septicemia • Increase length of stay • Premature mortality • Deformity

8. Pressure Ulcer • Localized injury to the skin and/or underlying tissue • 0ver a bony prominence • Result of pressure, or pressure in combination with shear.

9. Pressure • Pressure is the force that is applied perpendicular to the surface of the skin. • Compresses underlying tissue and small blood vessels hindering blood flow and nutrient supply. • Tissues become ischemic and are damaged or die.

10. Shear • Shear occurs when one layer of tissue slides horizontally over another, deforming adipose and muscle tissue, and disrupting blood flow. • Ex: when the head of the bed is raised > 30 degrees.

11. Bony Prominences • Occiput • Ear • Scapula • Spinous Process • Shoulder • Elbow • Iliac Crest • Sacrum/Coccyx • IschialTuberosity • Trochanter • Knee • Malleolus • Heel • Toe

12. Bony Prominences

13. Additional Areas • Any skin surface subjected to excess pressure • Oxygen tubing • Drainage tubing • Casts • Cervical collars

14. Time to Pressure Ulcer • Bed bound individuals form a pressure ulcer in as little as 1-2 hours. • Those in chairs may form a pressure ulcer in even less times because of greater relative force on skin.

15. Risk Assessment • Expert panels recommend use of risk assessment tools. • Tool is better than clinical judgment alone. • Scores are predictive of pressure ulcer formation. • Patients with a risk assessment have better documentation and more likely to have prevention initiated. • Braden Scale

16. Who do you screen? • Limited ability to reposition self in bed or chair • Stroke with residual deficits • Post-surgical • Paraplegic • Quadraplegic • Wheelchair bound • Bed bound

17. Braden Scale • Sensory perception • Moisture • Activity - degree of physical activity • Mobility – ability to change body position • Nutrition • Friction and Shear

19. Braden Scale – Sensory Perception • Ability to respond meaningfully to pressure-related discomfort. • Completely Limited • No moan/flinch, cannot feel pain most of body • Very Limited – • Responds only to pain, cannot feel pain ½ body • Slightly Limited – • Responds to command, cannot feel pain 1-2 limbs • No Impairment

20. Braden Scale - Moisture • Degree to which skin is exposed to moisture. • Constantly Moist • Very Moist • Often but not always, change sheets each shift • Occasionally Moist • Extra linen change a day • Rarely Moist • Only routine linen change

21. Braden Scale - Activity • Degree of physical activity. • Bedfast • Chairfast • Assisted into chair, cannot or barely walk • Walks Occasionally • Very short distance, most shift in bed • Walks Frequently • Walks outside room or in room every 2 hours

22. Braden Scale - Mobility • Ability to change and control body position. • Completely Immobile • Very Limited • Unable to make frequent or significant changes • Slightly Limited • Makes frequent but small changes • No Limitation

23. Braden Scale - Nutrition • Usual food intake pattern. • Very Poor • 1/3 meal, <2 servings protein, NPO w IVF • Probably Inadequate • ½ meal, 3 servings protein, poor tube feeds • Adequate • >1/2 meals, 4 servings protein, supps, TF or TPN • Excellent

24. Braden Scale – Friction and Shear • Sliding, rubbing against sheets, bed, chair, etc. • Problem • Mod-max assist, slides, cannot move without slide against sheets, spasticity, contractures, agitation • Potential Problem • Feeble, min assist, occ slides, indep moves with slide • No Apparent Problem

25. Braden Scale • Braden Scale score of 18 or less initiate prevention. • Score of 1 or 2 initiate specialty bed.

26. National Pressure Ulcer Advisory Panel

27. Partial and Full Thickness • Partial thickness wound involves ONLY the epidermis and dermis – Stage II. • Full thickness wound involves the epidermis and dermis and extends into deeper tissues (subcutaneous fat, muscle) – Stages III and IV.

28. Non-BlanchableErythema • The ulcer appears as a defined area of redness that does not blanch (become pale) under applied light pressure – Stage I.

29. Undermining • Tissue destruction underneath intact skin at the wound edge. • Wound edges are not attached to the wound base. • Edges overhang the periphery of the wound. • Pressure ulcer may be larger in area under the skin surface.

30. Undermining

31. Tunneling • Tunnel is a narrow channel of tissue loss that can extend in any direction away from the wound through soft tissue and muscle. • Tunnel may result in dead space which can complicate wound healing. • Depth of the tunnel can be measured using a cotton-tipped applicator or gloved finger.

32. Tunneling

33. Stage I

34. Stage I • INTACT SKIN. • NON-BLANCHABLE redness of a localized area. • Difficult to detect in individuals with dark skin tones - affected site is deeper in color. • Surrounding skin will feel different than effected area. • May indicate “at risk” persons.

35. Stage I

36. Stage II

37. Stage II • Partial thickness loss of dermis presenting as shallow open ulcer with a RED-PINK wound bed. • Shiny or dry shallow ulcer. • No slough or bruising. • BLISTER - intact, open or ruptured serum or serosangineous-filled. • Tissue surrounding the areas of epidermal loss are erythemic.

38. Stage II

39. Stage III

40. Stage III • FULL-THICKNESS tissue loss. • Subcutaneous fat may be visible. • Bone, tendon, or muscle is NOT visible or directly palpable. • Slough may be present but does NOT obscure the depth of tissue loss. • May include undermining and tunneling.

41. Stage III • 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 so Stage III ulcers can be shallow. • Areas of significant adiposity can develop extremely deep Stage III pressure ulcers.

42. Stage III

43. Stage IV

44. Stage IV • FULL-THICKNESS tissue loss. • BONE, TENDON, or MUSCLE is visible or directly palpable. • Slough or eschar may be present but does NOT obscure wound bed. • Often includes undermining and tunneling. • Can extend into supporting structures (fascia, tendon or joint capsule) making osteomyelitis or osteitis likely .

45. Stage IV • 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.

46. Stage IV

47. Unstageable

48. Unstageable • FULL-THICKNESS tissue loss in which SLOUGH (yellow, tan, gray, green, or brown), ESCHAR (tan, brown, or black), or both COVER the base of the ulcer. • Cannot determine true depth of wound secondary to slough and/or eschar. • Will be either a Stage III or IV.

49. Unstageable

50. Deep Tissue Injury