Introduction to Pressure Ulcers

1. 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.

3. 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

4. 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.

5. 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.

6. Pressure Ulcer Risk Factors Immobility, decreased functional ability Co-morbid conditions (ESRD, thyroid) Diabetes Drugs such as steroids Impaired diffuse or localized blood flow

7. 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

8. Pressure Ulcer Assessment Staging Categorizing pressure ulcers in terms of depth of tissue loss Stages 1-4 and Unstageable Distinguishing pressure ulcers from wounds/skin conditions Imperative to differentiate the etiology for proper treatment and management of wound.

9. General Assessment Guidelines Review the medical record. Examine the patient. Perform a head-to-toe, full body skin assessment. Focus on bony prominences and pressure-bearing areas. Use visual inspection and palpation. Ensure a comprehensive assessment.

10. 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.

11. Staging Pressure Ulcers

12. Staging Definitions CMS has adaptedthe 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

13. Stage 1 Pressure Ulcers

14. Stage 1 Pressure Ulcer Intact skin with non-blanchable rednessof a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching. Color may differ from the surrounding area.

15. Assessing Stage 1 Pressure Ulcers Perform a head-to-toe, full body skin assessment. Focus on bony prominences and pressure-bearing areas: Sacrum Heels Buttocks Ankles

16. Assessing Stage 1 Pressure Ulcers2 • Consider where patient spends time. • Check any reddened areas for ability to blanch. • Firmly press finger into tissue, then remove. • Non-blanchable: no loss of skin color or pressure-induced pallor at the compressed site

17. Assessing Stage 1 Pressure Ulcers3 • Search for other areas of skin that differ from surrounding tissue. • Painful • Firm • Soft • Warmer/ cooler • Color change • Assessment to determine staging should be comprehensive. • Stage 1 ulcers may be difficult to detect in individuals with dark skin tones.

18. 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).

19. Is This a Stage 1 Pressure Ulcer?

20. Stage 2 Pressure Ulcers

21. Stage 2 Pressure Ulcer Partial thickness loss of dermis presenting as: Shallow open ulcer Red or pink wound bed Without slough

22. Stage 2 Pressure Ulcer, Cont. May also present as an intact or open/ ruptured blister

23. Assessing Stage 2 Pressure Ulcers Perform a head-to-toe, full body skin assessment. Focus on bony prominences and pressure-bearing areas.

24. Assessing Stage 2Pressure Ulcers, Cont. Examine the area adjacent to or surrounding any intact blister for evidence of tissue damage. Color change Tenderness Bogginess or firmness 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.

25. DifferentiatingStage 2 Pressure Ulcers Confirm that the wound being assessed is primarily related to pressure. Rule out other conditions. Do not identify a wound as a pressure ulcer if pressure is not the primary cause.

26. 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.

27. Differentiating Stage 2 Pressure Ulcers3 Do not identify the following as pressure ulcers: Skin tears Tape burns Moisture associated Skin Damage from incontinence Excoriation

28. Is This a Stage 2 Pressure Ulcer? What steps should you take to assess this? Is this a Stage 2 pressure ulcer?

29. Is This a Stage 2 Pressure Ulcer? What steps should you take to assess this? Is this a Stage 2 pressure ulcer?

30. Is This a Stage 2 Pressure Ulcer? • What steps should you take to assess this? • Is this a Stage 2 pressure ulcer?

31. Stage 3 and 4 Pressure Ulcers

32. Stage 3 Pressure Ulcer Full thickness tissue loss Subcutaneous fat may be visible but bone, tendon or muscle is notexposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

33. Stage 4 Pressure Ulcer Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be presenton some parts of the wound bed. Oftenincludes undermining and tunneling. Depth varies by anatomical location (bridge of nose, ear, occiput, and malleous ulcers can be shallow).

34. 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.

35. Reverse Staging Do not reverse stage. 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. Currently, it is required that it continue to be documented as a Stage 4 until completely healed.

36. 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?

37. Unstageable Pressure Ulcers

38. Unstageable Pressure Ulcers Three types to differentiate: Unstageable due to Non-Removable Device or Dressing Unstageable due to Slough and/or Eschar Unstageable due to Suspected Deep Tissue Injury (sDTI)

39. UnstageableNon-Removable Device Ulcer covered with eschar under plaster cast Known but not stageable because of the non-removable device

40. UnstageableNon-Removable Dressing Known but not stageable because of the non-removable dressing

41. 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

42. 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

43. 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.

44. 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?

45. 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.

46. Pressure UlcerStaging Quiz

47. Pressure Ulcer Quiz #1 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable -Slough or Eschar Unstageable - sDTI

48. Stage 1 Stage 2 Stage 3 Stage 4 Unstageable -Slough or Eschar Unstageable - sDTI Pressure Ulcer Quiz #2

49. Stage 1 Stage 2 Stage 3 Stage 4 Unstageable -Slough or Eschar Unstageable - sDTI Pressure Ulcer Quiz #3

50. Pressure Ulcer Quiz #4 • Stage 1 • Stage 2 • Stage 3 • Stage 4 • Unstageable - Slough or Eschar • Unstageable - sDTI