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Introduction to Pressure Ulcers. 2 Impacts of Pressure Ulcers Pressure ulcers affect quality of life for patients: Limit activity. Are painful. Require.

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Presentation on theme: "Introduction to Pressure Ulcers. 2 Impacts of Pressure Ulcers Pressure ulcers affect quality of life for patients: Limit activity. Are painful. Require."— Presentation transcript:

1 Introduction to Pressure Ulcers

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

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

10 Introduction to Pressure Ulcers 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 Introduction to Pressure Ulcers 12 Staging Definitions CMS has adapted the 2007 NPUAP definitions for categories of staging. Resource: Free diagrams of ulcer stages can be downloaded for educational use. Reproduced with permission

13 Stage 1 Pressure Ulcers

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

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

16 Introduction to Pressure Ulcers 16 Assessing Stage 1 Pressure Ulcers 2 Consider where patient spends time. Check any reddened areas for ability to blanch. o Firmly press finger into tissue, then remove. o Non-blanchable: no loss of skin color or pressure-induced pallor at the compressed site

17 Introduction to Pressure Ulcers 17 Assessing Stage 1 Pressure Ulcers 3 Search for other areas of skin that differ from surrounding tissue. o Painful o Firm o Soft o Warmer/ cooler o Color change Assessment to determine staging should be comprehensive. Stage 1 ulcers may be difficult to detect in individuals with dark skin tones.

18 Introduction to Pressure Ulcers 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 Introduction to Pressure Ulcers 19 Is This a Stage 1 Pressure Ulcer?

20 Stage 2 Pressure Ulcers

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

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

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

24 Introduction to Pressure Ulcers 24 Assessing Stage 2 Pressure Ulcers, Cont. Examine the area adjacent to or surrounding any intact blister for evidence of tissue damage. o Color change o Tenderness o Bogginess or firmness o 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 Introduction to Pressure Ulcers 25 Differentiating Stage 2 Pressure Ulcers Confirm that the wound being assessed is primarily related to pressure. o Rule out other conditions. o Do not identify a wound as a pressure ulcer if pressure is not the primary cause.

26 Introduction to Pressure Ulcers 26 Differentiating Stage 2 Pressure Ulcers 2 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 Introduction to Pressure Ulcers 27 Differentiating Stage 2 Pressure Ulcers 3 Do not identify the following as pressure ulcers: o Skin tears o Tape burns o Moisture associated Skin Damage from incontinence o Excoriation

28 Introduction to Pressure Ulcers 28 Is This a Stage 2 Pressure Ulcer? 1.What steps should you take to assess this? 2.Is this a Stage 2 pressure ulcer?

29 Introduction to Pressure Ulcers 29 Is This a Stage 2 Pressure Ulcer? 1.What steps should you take to assess this? 2.Is this a Stage 2 pressure ulcer?

30 Introduction to Pressure Ulcers 30 Is This a Stage 2 Pressure Ulcer? 1.What steps should you take to assess this? 2.Is this a Stage 2 pressure ulcer?

31 Stage 3 and 4 Pressure Ulcers

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

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

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

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

39 Introduction to Pressure Ulcers 39 Unstageable Non-Removable Device Ulcer covered with eschar under plaster cast Known but not stageable because of the non- removable device

40 Introduction to Pressure Ulcers 40 Unstageable Non-Removable Dressing Known but not stageable because of the non-removable dressing

41 Introduction to Pressure Ulcers 41 Unstageable Slough and/or Eschar Known but not stageable due to coverage of wound bed by slough and/or eschar Full thickness tissue loss Base of ulcer covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed

42 Introduction to Pressure Ulcers 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 Unstageable Suspected Deep Tissue Injury

43 Introduction to Pressure Ulcers 43 Unstageable Suspected 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 Introduction to Pressure Ulcers 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 Introduction to Pressure Ulcers 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 Ulcer Staging Quiz

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

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

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

50 Introduction to Pressure Ulcers 50 Pressure Ulcer Quiz #4 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable - Slough or Eschar Unstageable - sDTI

51 Introduction to Pressure Ulcers 51 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable - Slough or Eschar Unstageable - sDTI Pressure Ulcer Quiz #5

52 Introduction to Pressure Ulcers 52 Pressure Ulcer Quiz #6 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable - Slough or Eschar Unstageable - sDTI

53 Introduction to Pressure Ulcers 53 Pressure Ulcer Quiz #7 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable - Slough or Eschar Unstageable - sDTI

54 Introduction to Pressure Ulcers 54 Pressure Ulcer Quiz #8 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable - Slough or Eschar Unstageable - sDTI

55 Introduction to Pressure Ulcers 55 Pressure Ulcer Quiz #9 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable - Slough or Eschar Unstageable - sDTI

56 Differentiating Pressure Ulcers from Other Wounds/ Skin Conditions

57 Introduction to Pressure Ulcers 57 Importance of Wound Differentiation There are a variety of other wound types in addition to pressure ulcers. Differentiating wounds requires knowledge, experience, patient history/ events, and interdisciplinary collaboration. A comprehensive assessment is needed. Differentiating the etiology of the wound is essential to determine and direct the proper treatment and management of the wound.

58 Introduction to Pressure Ulcers 58 Wounds and Skin Conditions Venous and Arterial Ulcers Diabetic Foot Ulcers Open Lesions Other than Ulcers, Rashes, Cuts Surgical Wounds Burns Skin Tears Moisture-Associated Skin Damage (MASD)

59 Introduction to Pressure Ulcers 59 Venous Ulcers May be result of minor trauma. Usual location is lower leg area or medial or lateral malleolus. Characterized by: o Irregular wound edges o Hemosiderin staining o Leg edema

60 Introduction to Pressure Ulcers 60 Arterial Ulcers May be result of minor trauma. Usual location: o Toes o Top of foot o Distal to medial malleolus

61 Introduction to Pressure Ulcers 61 Characteristics of Arterial Ulcers Necrotic tissue or pale pink wound bed Diminished or absent pulses Trophic skin changes: o Dry skin o Loss of hair o Brittle nails o Muscle atrophy

62 Introduction to Pressure Ulcers 62 Diabetic Foot Ulcers Caused by the neuropathic and small blood vessel complications of diabetes. Usual location: Over plantar (bottom) surface of foot on load bearing areas

63 Introduction to Pressure Ulcers 63 Characteristics of Diabetic Foot Ulcers Usually deep, with necrotic tissue, moderate amounts of exudate and calloused wound edges Very regular in shape; wound edges are even, with a punched-out appearance Even though patient has neuropathy, may have pain

64 Introduction to Pressure Ulcers 64 Open Lesions Other than Ulcers, Rashes, Cuts Typically, skin ulcers that develop as a result of diseases and conditions such as syphilis and cancer. Patient history is helpful to identify wound etiology. Type of skin condition will determine location.

65 Introduction to Pressure Ulcers 65 Surgical Wounds Healing or non-healing, open or closed surgical incisions Skin grafts Drainage sites Surgical flap to repair a pressure ulcer

66 Introduction to Pressure Ulcers 66 Burns Skin and tissue injury caused by heat or chemicals. Patient history of events is helpful to differentiate etiology and type of burn. May be in any stage of healing.

67 Introduction to Pressure Ulcers 67 Skin Tears Are acute traumatic wounds. May occur as a result of shear, friction or trauma to the skin. The epidermis separates from the dermis. Usually occur on the extremities of older adults.

68 Introduction to Pressure Ulcers 68 Characteristics of Skin Tears Often painful Part or all of epidermis (skin flap may be present) Shallow wounds Bleeding may be present

69 Introduction to Pressure Ulcers 69 Moisture-Associated Skin Damage Occurs with sustained exposure to moisture Several etiologies associated with MASD oExample: urinary or fecal incontinence Location of MASD associated with its etiology

70 Introduction to Pressure Ulcers 70 Characteristics of Moisture- Associated Skin Damage Inflammation and erosion of the skin Very diffuse, with reddened, superficial area(s) Initially superficial but further damage may result from factors such as pressure May have superimposed fungal infection (on top of MASD) No necrotic tissue

71 Introduction to Pressure Ulcers 71 Assessing Wounds/ Skin Conditions Review the medical record. oSkin care flow sheet or other skin tracking form. oTreatment records and orders for documented treatments. Speak with direct care staff and treatment nurse. oConfirm conclusions from medical record review. Examine the patient. oDetermine if ulcers, wounds, or skin problems are present. oObserve skin treatments.

72 Introduction to Pressure Ulcers 72 Scenario #1 What Type of Skin Condition? A patient has diabetes mellitus. He presents with an ulcer on the heel that is due to pressure. Is this a pressure ulcer or another skin condition?

73 Introduction to Pressure Ulcers 73 Scenario #2 What Type of Skin Condition? A patient is readmitted from the hospital after flap surgery to repair a sacral pressure ulcer. Is this a pressure ulcer or another skin condition?

74 Wound Quiz

75 Introduction to Pressure Ulcers 75 Wound Quiz #1

76 Introduction to Pressure Ulcers 76 Wound Quiz #2

77 Introduction to Pressure Ulcers 77 Wound Quiz #3

78 Introduction to Pressure Ulcers 78 Wound Quiz #4

79 Introduction to Pressure Ulcers 79 Wound Quiz #5

80 Introduction to Pressure Ulcers 80 Wound Quiz #6

81 Introduction to Pressure Ulcers 81 Wound Quiz #7

82 Introduction to Pressure Ulcers 82 Wound Quiz #8

83 Introduction to Pressure Ulcers 83 Wound Quiz #9

84 Introduction to Pressure Ulcers 84 Wound Quiz #10

85 Introduction to Pressure Ulcers 85 Wound Quiz #11


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