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. 2

3. Presentation Addresses:
What is a pressure ulcer (the definition)
Risk factors
General guidelines for assessment
Staging pressure ulcers
Differentiating pressure ulcers from other wounds/ skin conditions 3

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. 4

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. 5

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 6

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 7 7

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. 8 8

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. 9 9

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. 10 10

11. Staging Pressure Ulcers11

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 12 12

13. Stage 1 Pressure Ulcers 13

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. 14 14

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 15 15

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 16 16

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. 17 17

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). 18 18

19. Is This a Stage 1 Pressure Ulcer?19 19

20. Stage 2 Pressure Ulcers 20

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

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

23. Assessing Stage 2 Pressure Ulcers
Perform a head-to-toe, full body skin assessment.
Focus on bony prominences and pressure- bearing areas.
Ensure a complete and comprehensive assessment of the patient and the site of injury. 23 23

24. Assessing Stage 2 Pressure 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. 24 24

25. Differentiating Stage 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. 25 25

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. 26 26

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 27 27

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

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

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

31. Stage 3 and 4 Pressure Ulcers31

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 32 32

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). 33 33

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. 34 34

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. 35 35

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? 36 36

37. Unstageable Pressure Ulcers37

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) 38 38

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

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

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 41 41

42. Unstageable Suspected Deep Tissue Injury
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 42 42

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. 43 43

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? 44 44

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. 45 45

46. Pressure Ulcer Staging Quiz46

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

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

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

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

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

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

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

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

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

56. Differentiating Pressure Ulcers from Other Wounds/ Skin Conditions56

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. 57 57

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) 58 58

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

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

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

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 62 62

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 63 63

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. 64 64

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

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. 66 66

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. 67 67

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

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

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 70 70

71. Assessing Wounds/ Skin Conditions
Review the medical record.
Skin care flow sheet or other skin tracking form.
Treatment records and orders for documented treatments.
Speak with direct care staff and treatment nurse.
Confirm conclusions from medical record review.
Examine the patient.
Determine if ulcers, wounds, or skin problems are present.
Observe skin treatments. 71 71

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? 72 72

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? 73 73

74. Wound Quiz 74

75. Wound Quiz #1
Arterial Ulcer 75 75

76. Wound Quiz #2
Pressure Ulcer 76 76

77. Wound Quiz #3
Diabetic Foot Ulcer 77 77

78. Wound Quiz #4
Burn 78 78

79. Wound Quiz #5
Arterial Ulcer 79 79

80. Wound Quiz #6
Arterial Ulcer 80 80

81. Wound Quiz #7
Pressure Ulcer 81 81

82. Wound Quiz #8
Venous Ulcer 82 82

83. Wound Quiz #9
MASD 83 83

84. Wound Quiz #10
Skin Tear or Surgical Wound 84 84

85. Wound Quiz #11
Pressure Ulcer 85 85