Presentation on theme: "Pressure Ulcers: Staging and Risk Assessment"— Presentation transcript:
1Pressure Ulcers: Staging and Risk Assessment Keri Holmes-Maybank, MDMedical University of South Carolina
2Learning objectivesResidents 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.
3Key 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.
5Pressure Ulcers 2.5 million hospitalized patients/yr 60,000 die/yr from pressure ulcer complications1 in 25 if pressure ulcer reason for admit1 in 8 if pressure ulcer secondary diagnosis10-18% acute care patients0.4-38% acute care new ulcers
6Pressure Ulcers80% increase pressure ulcer related hospitalizationsLength of Stay days (average LOS 5 days)$ billion in 2008awards avg $13.5 million$312 million in one case
7Impact on Patients Reduces quality of life Interfere with basic activities of daily livingIncreased painDecrease functional abilityInfection – OM and septicemiaIncrease length of stayPremature mortalityDeformity
8Pressure Ulcer Localized injury to the skin and/or underlying tissue 0ver a bony prominenceResult of pressure, or pressure in combination with shear.
9PressurePressure 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.
10ShearShear 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.
13Additional Areas Any skin surface subjected to excess pressure Oxygen tubingDrainage tubingCastsCervical collars
14Time to Pressure UlcerBed 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.
15Risk 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
16Who do you screen? Limited ability to reposition self in bed or chair Stroke with residual deficitsPost-surgicalParaplegicQuadraplegicWheelchair boundBed bound
17Braden Scale Sensory perception Moisture Activity - degree of physical activityMobility – ability to change body positionNutritionFriction and Shear
19Braden Scale – Sensory Perception Ability to respond meaningfully to pressure- related discomfort.Completely LimitedNo moan/flinch, cannot feel pain most of bodyVery Limited –Responds only to pain, cannot feel pain ½ bodySlightly Limited –Responds to command, cannot feel pain 1-2 limbsNo Impairment
20Braden Scale - Moisture Degree to which skin is exposed to moisture.Constantly MoistVery MoistOften but not always, change sheets each shiftOccasionally MoistExtra linen change a dayRarely MoistOnly routine linen change
21Braden Scale - Activity Degree of physical activity.BedfastChairfastAssisted into chair, cannot or barely walkWalks OccasionallyVery short distance, most shift in bedWalks FrequentlyWalks outside room or in roomevery 2 hours
22Braden Scale - Mobility Ability to change and control body position.Completely ImmobileVery LimitedUnable to make frequent or significant changesSlightly LimitedMakes frequent but small changesNo Limitation
24Braden Scale – Friction and Shear Sliding, rubbing against sheets, bed, chair, etc.ProblemMod-max assist, slides, cannot move without slide against sheets, spasticity, contractures, agitationPotential ProblemFeeble, min assist, occ slides, indep moves with slideNo Apparent Problem
25Braden Scale Braden Scale score of 18 or less initiate prevention. Score of 1 or 2 initiate specialty bed.
27Partial 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.
28Non-Blanchable Erythema The ulcer appears as a defined area of redness that does not blanch (become pale) under applied light pressure – Stage I.
29UnderminingTissue 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.
31TunnelingTunnel 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.
34Stage 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.
37Stage IIPartial 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.
40Stage 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.
41Stage IIIThe 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.
44Stage 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 .
45Stage IVThe 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.
48UnstageableFULL-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.
51Deep 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.
52Deep 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.
55Skin TearSeparation of epidermis from the dermis or epidermis and dermis from underlying tissue.Thin skin, less elastic, purpura or ecchymosis.Epidermal flap.
56Arterial Ulcers Impaired arterial flow to the lower leg and foot. Tissue ischemia, necrosis and lossWELL DEFINED MARGINSToes, foot, malleolusThin, shiny skin, cool skin temperature, decreased or absent hairPainful - increase with elevationDecreased pulseMinimal exudatePale wound bed; necrotic tissue
57Venous 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 thewound is reddened.
58Diabetic Ulcers Ulcer that occurs in diabetics Metatarsal head, top of toes, and footNeuropathy, poor microvascular circulationRepetitive trauma, unperceived pressure, or friction/shearRegular wound marginsCallus around woundDry, cracked, warm
59Perineal 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 andvesicle formation .Tissue “weeping”.
61ReferencesNational 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.https://www.nursingquality.orgPanel 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.