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
Length of Stay days (average LOS 5 days)
$ billion in 2008
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
Ischial Tuberosity
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-Blanchable Erythema
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

51. Deep Tissue Injury INTACT SKIN. PURPLE or MAROON.
BLOOD FILLED BLISTER.
May be difficult to detect in individuals with dark skin tones.
Color and mechanical stiffness of the skin (firm, mushy, boggy) assist in differentiating between DTI and a Stage I pressure ulcer.

52. Deep Tissue Injury Most common:
Sacrum, buttocks and heels.
Heel may look like a bruise or a blood blister.
1% resolve spontaneously.
Evolution:
Thin blister over a dark wound bed.
Covered by thin eschar.
May rapidly evolve.
Likely become a Stage III or IV.

53. Deep Tissue Injury

54. Not Pressure Ulcers Skin Tears Venous Ulcers Arterial Ulcers
Diabetic Ulcers
Perineal (Incontinence Associated) Dermatitis

55. Skin Tear
Separation of epidermis from the dermis or epidermis and dermis from underlying tissue.
Thin skin, less elastic, purpura or ecchymosis.
Epidermal flap.

56. Arterial Ulcers Impaired arterial flow to the lower leg and foot.
Tissue ischemia, necrosis and loss
WELL DEFINED MARGINS
Toes, foot, malleolus
Thin, shiny skin, cool skin temperature, decreased or absent hair
Painful - increase with elevation
Decreased pulse
Minimal exudate
Pale wound bed; necrotic tissue

57. Venous Ulcers Decrease in blood return from leg and foot.
Between the knee and the ankle.
Thickened, brown discolored skin is noted around the lower calf, ankle and proximal foot.
Skin proximal and distal to the
wound is reddened.

58. Diabetic Ulcers Ulcer that occurs in diabetics
Metatarsal head, top of toes, and foot
Neuropathy, poor microvascular circulation
Repetitive trauma, unperceived pressure, or friction/shear
Regular wound margins
Callus around wound
Dry, cracked, warm

59. Perineal Dermatitis (Incontinence Associated)
Skin irritation from incontinence.
Erosion of epidermis and dermis from mechanical injury to macerated skin.
Buttocks, perineum, and upper thighs.
Secondary infection.
Diffuse erythema.
Scaling, papule and
vesicle formation .
Tissue “weeping”.

60. DOCUMENT!!!!!!

61. References
National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers: Clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel.
Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Prediction and Prevention. Rockville MD. Agency for Health Care Policy and Research May. AHCPR Clinical Practice Guidelines, No. 3.
Bates-Jensen BM, MacLean CH. Quality Indicators for the Care of Pressure Ulcers in Vulnerable Elders. JAGS 55:S409-S416, 2007.