PRESSURE ULCERS: The Basics A QUALITY APPROACH

1. PRESSURE ULCERS: The BasicsA QUALITY APPROACH Bridgepoint I, Suite 300 5918 West Courtyard Drive Austin, TX 78730-5036 1-866-439-5863 www.tmf.org Logo for TMF Health Quality Insurance appears in the upper left hand corner of each slide in this presentation

2. Objectives The learner will be able to: • Describe five major causes of pressure ulcers • Differentiate stages of pressure ulcers based on degree of tissue involvement • Create a pressure ulcer preventionintervention plan

3. Disclaimer TMF Health Quality Institute has no relevant financial relationships to disclose. TMF does not accept commercial support from other organizations or companies for the development of Continuing Nursing Education activities.

4. Definition of Pressure Ulcer Any lesion caused by unrelieved pressure resulting in damage of underlying tissue. U.S. Department of Health and Human Services Agency for Healthcare Research and Policy www.ahrq.gov

5. A Pressure Ulcer is • A localized area of tissue injury • Caused by unrelieved pressure • Usually located over bony prominences

6. Scope of the Problem • Cost of treating a pressure ulcer: $5,000 - $60,000 • 5,737 individuals with pressure ulcers* in Texas • 659 are low risk individuals* • Treating these numbers for just one pressure ulcer at only $5,000 would cost $28,685,000! • $78,589 per day (Texas) *Quality Indicators Quarter 1 - 2005

7. National Goal Healthy People 2010 initiative target: Less than a 1% incidence of avoidable pressure ulcers (Target: 8 diagnoses per 1,000 residents) Current as of 08/24/2005 www.healthypeople.gov/document/html/objectives/01-16.htm

8. Pressure Ulcer Causes Tissue ischemia* or damage due to: • Prolonged pressure which depends on: • Duration and intensity of pressure • Location of pressure on body *ischemia (isch- is restriction, hema is blood)

9. Best Treatment Option AVOIDANCE!

10. Evaluation • Staging describes the extent of tissue involvement • Stage I, II, III, IV and unstageable • As stages increase, deeper tissues are involved

11. Soft Tissue Anatomy • 2 Layers of Skin • Epidermis • Outer protective layer • Dermis • Inner vascular layer, sensation, temperature regulation • Subcutaneous Layers • Fatty layer • cushioning, insulation • Muscle • Tendon, ligament • Bone • Joint capsule

12. Age Related Changes Slide Notes: Papillary dermis: loosed its definition, becomes less able to anchor the tissues Melanocytes: that give skin its color and helps to protect against sun rays decreases. Skin becomes paler in color

13. Common Sites Slide Notes: Common sites for pressure ulcers Sacrum & Coccyx (65%) Trochanter (9%) Ischium (4%) Knee (3%) Tibia (2%) Heel & Ankle (15%)

14. Common Sites Slide notes: The prevalence of pressure ulcer development is highest among the elderly and it has been estimated that 70% of pressure ulcers occur in residents over 70 years of age. Source: High Mark Security Blue (A Medicare Choice HMO) 5/2000 The hip and buttock regions account for 67% of all pressure ulcers, with ischial tuberosity, trochanter, and sacral locations to be the most common. The lower extremities account for an additional 25% of pressure sores, with malleolar, heel, patellar, and pretibial locations being most common. The remaining 10% may occur in any location that experience long uninterrupted pressure. Nose, chin, forehead, occiput, chest, back and elbow are among the most common of the infrequent sites for pressure ulceration. Pressure ulcers form where bone causes the greatest force on the skin and tissue and squeezes them against an outside surface. This may be where bony parts of the body press against other body parts, a mattress, or a chair. In persons who must stay in bed, most pressure ulcers form on the lower back below the waist, the hip bone, and on the heels. In people in wheelchairs, the exact spot where pressure ulcers form depends on the sitting position. Pressure ulcers can also form on the knees, ankles, shoulder blades, back of head and spine. Nerves normally tell the body when to move to relieve pressure on the skin. Residents in bed who are unable to move may get pressure ulcers after as little as 1-2 hours. Residents who sit in chairs and who cannot move can get pressure ulcers in even less time because the force on the skin is greater.

15. Tend to Occur at Bony Prominences • Sacrum---tail bone, most common site • Avoid, semi-Fowler’s position or slouching in bed or chair

16. Other Bony Prominences • Trochanter---hip bone • Side lying, contracture patients at highest risk • Lateral foot vs. heel • Ischium---sit here when erect • Paraplegics at highest risk

17. Wound Staging: Stage I An observable pressure-related alteration of intact skin . . . www.npuap.org/postn6 July 20, 2005 Slide Notes: (Read slide) Source: National Pressure Ulcer Advisory Panel Pressure Ulcer Classification. NPUAP Consensus development conference statement. Decubitus 2, 24, 1989. The ulcer appears as a defined area of persistent redness in lightly pigmented skin . . Darker skin tones may appear with persistent red, blue, or purple hues. Staging is an approved classification system for assessing depth of pressure ulcer injury. This system is recommended by National Pressure Ulcer Advisory Panel (NPUAP), The Agency for Health Care Policy and Research (AHCPR), and the Wound , Ostomy and Continence Nurses Society, (WOCN).

18. Stage I: Definition • May be difficult to identify • May have minimal to substantial tissue damage in layers much deeper than is apparent • Persists or remains evident 30 – 45 minutes after pressure removed • May appear red, blue, or purple in persons with darker skin tones   (NPUAP 2002)

19. Stage I: Definition • May be • Warmer or cooler • Firm or boggy • Painful or itchy • No open area in the skin

20. Stage I

21. Stage I

22. Stage I: Detection • With each repositioning, inspect the bony prominences (hips, sacrum, heel, coccyx) upon which the person was lying • Inspect the heels • Use a mirror if needed

23. Wound Staging: Stage II • Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater www.npuap.org/postn6 July 20, 2005 Slide Notes: (Read slide) Source: National Pressure Ulcer Advisory Panel Pressure Ulcer Classification. NPUAP Consensus development conference statement. Decubitus 2, 24, 1989. Staging is an approved classification system for assessing depth of pressure ulcer injury. This system is recommended by National Pressure Ulcer Advisory Panel (NPUAP), The Agency for Health Care Policy and Research (AHCPR), and the Wound , Ostomy and Continence Nurses Society, (WOCN).

24. Stage II

25. Stage II • Partial thickness skin loss (shallow) • Looks like an abrasion or blister • Normal surrounding skin

26. Stage II: Detecting • Inspect skin for shallow wounds or shiny areas of skin loss • Do not classify skin tears or erosion from urine or feces as Stage II • Do not include wounds covered with slough Slide Notes: Slough - necrotic/avascular tissue in the process of separating from the viable portions of the body ; light colored, soft, moist and stringy

27. Stage III • Full thickness skin loss • Damage or necrosis of subcutaneous tissue • May extend down to but not through underlying fascia • A deep crater with possible undermining of adjacent tissue • Ulcer bed may be subcutaneous fat, slough, necrosis or granulation tissue

28. Stage III

29. Stage III Slide Notes: Stage III – full thickness of skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; ulcer presents as a deep crater with or without undermining of adjacent tissue. The average healing time for a Stage III ulcer is 90 days.

30. Stage III:Detection • Inspect all skin for wounds • Do not label deep wounds covered with nonviable tissue as Stage III • Label as unstageable

31. Stage III:Detection • Evaluate ulcer for evidence of infection • Redness • Swelling • Pain • Warmth • Exudate

32. Wound Staging: Stage IV • Full thickness skin loss • Extensive destruction, necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint, capsule) • Undermining and sinus tracts also may be associated with Stage IV pressure ulcers www.npuap.org/postn6 July 20, 2005 Slide Notes: (Read slide) Source: National Pressure Ulcer Advisory Panel Pressure Ulcer Classification. NPUAP Consensus development conference statement. Decubitus 2, 24, 1989. Staging is an approved classification system for assessing depth of pressure ulcer injury. This system is recommended by National Pressure Ulcer Advisory Panel (NPUAP), The Agency for Health Care Policy and Research (AHCPR), and the Wound , Ostomy and Continence Nurses Society, (WOCN).

33. Stage IV

34. Stage IV Slide Notes: Stage IV – full thickness of skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or support structures such as deep fascia, tendon, or joint capsule. When eschar (Thick, leathery necrotic tissue) is present, a pressure ulcer cannot be accurately staged until the eschar is removed. • It may be difficult to assess pressure ulcers in patients with casts, other orthopedic devices, or support stockings. Extra vigilance is required to assess ulcers under these circumstances. • If you can’t see the base ( Wound base -Uppermost viable tissue layer of wound) of the ulcer, you can’t stage the ulcer. • The average healing time for a Stage IV ulcer is 120 days.

35. Stage IV: Detecting • Inspect all skin for wounds • Palpate or gently probe with sterile applicator to feel for bone • Do not label ulcers with necrotic tissues (Eschar or Slough) as Stage IV • Unstageable

36. Slough • Necrotic/avascular tissue, separating from viable portions of the body • Usually light colored, soft, moist • Stringy (at times)

37. Eschar • Devitalized dermis – leathery or thick and black • If reinjured or suffers further avascular necrosis from compromised local circulation, the necrotic tissue turns thick, leathery and black

38. So What is the Difference? • Tunneling? • Sinus tract? • Undermining? • Fistula?

39. Tunneling • A passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound or hollow viscous

40. Sinus Tract • A cavity or channel underlying a wound that involves an area larger than the visible survey of the wound

41. Undermining • An area of destruction of tissue or ulceration extending under the skin edges (margins) so that the ulcer is larger at the base than at the skin surface

42. Fistula • A tunnel or sinus tract that ends in another structure or hollow viscous

43. Un-Stageable • Wound covered by necrotic tissue or slough • Unable to see wound base, thus cannot assess depth • Usually seen as a cap over necrotic tissue • Leather-like appearance

44. Un-Stageable • Cannot assess extent of tissue damage with eschar • Documentation includes • Length and width • Depth is highly questionable (describe exactly what you see) • Hard – Dry • Black – Non-viable tissue www.npuap.org/postn6 July 20, 2005

45. Un-Stageable Ulcer is covered with eschar or slough. True base of the wound cannot be seen.

46. Deep Tissue Injury • A new description of pressure ulcers • Begins in subdermal tissue • Initially appears purple or blue, usually leads to denuding of the epidermis and eschar formation • Do not stage as Stage I

47. Best Treatment Option AVOIDANCE!

48. Use Appropriate Staging Systems

49. NPUAP Staging: • Pressure ulcers only • Other wounds should be described as full or partial thickness • (e.g., arterial ulcers – there is no staging system available)

50. When to Stage • At time of initial assessment or if ulcer deteriorates (the highest stage defines the wound) • With improvement, label ulcer with original stage as “healing” (e.g., a “healing Stage III”)