Staging of Wounds are based on the deepest level of tissue damage

Pressure Ulcer
Staging
Staging of Wounds are based
on the deepest level of tissue
damage
Pressure Ulcer Staging
New Pressure Ulcer Staging
Stage I
 Stage II
 Stage III
 Stage IV
 Unstageable
 Suspected Deep Tissue Injury
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Pressure Ulcer Staging
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This staging system should be used
only to describe pressure ulcers
• Wounds from other causes: should
not use this staging system:
arterial, venous, diabetic foot, skin
tears, tape burns, perineal
dermatitis, maceration or
excoriation
Definition of a Pressure Ulcer
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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
WHO is Responsible?????
Licensed personnel responsible for
patient assessment
Pressure Ulcers Occur
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Over bony prominences
Primary sites: sacrum & heels (75%)
95% of all pressure ulcers sites:
sacral/coccygeal area, greater
trochanter, ischial tuberosity, heel,
and lateral malleolus
Forgotten pressure ulcer sites:
pressure on ears from oxygen
tubing, and occiput
Pressure Ulcer Measurement
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Measure in cms
Measure length & width like hands of a
clock
• Length: 12 o’clock to 6 o’clock (head to
toe)
• Width: 9 o’clock to 3 o’clock (side to
side)
Measure depth using applicator
• Insert applicator into wound base. Place
fingers along side of applicator to
surrounding tissue. (compare against
measuring guide)
Documentation
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Document:
• Stage Pressure Ulcer
• Describe wound base color in %
• Describe drainage color, amount,
presence of odor
• Describe surrounding tissue
blanchability, color, s/s of infection
Pressure Ulcer: Stage I
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Stage I pressure ulcer is intact skin
with nonblanchable redness of a
localized area usually over a bony
prominence.
• Darkly pigmented skin may not have
visible blanching; its color may differ
from surrounding tissue
• The area may be painful, firm, softer,
warmer or cooler as compared to
adjacent tissue
Stage I
Pressure Ulcer Staging Stage I
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Import picture
Pressure Ulcer Staging Stage II
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Stage II pressure ulcer is partial
thickness loss of dermis presenting
as a shallow open ulcer with a red
pink wound bed, without slough.
• May present as an intact or
open/ruptured blister
• Presents as a shiny or dry shallow ulcer
without slough or bruising (change in
definition)
Stage II
Pressure Ulcer Staging Stage II
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Import picture
Pressure Ulcer Staging Stage II
Pressure Ulcer Staging Stage III
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Stage III pressure ulcer is full
thickness tissue loss, subcutaneous
fat may be visible but bone, tendon,
muscle are not exposed. Slough may
be present but does not obscure the
depth of tissue loss
• Undermining and tunneling may be
present
• The depth of a Stage III pressure ulcer
can vary by anatomical location
Stage III
Pressure Ulcer Staging Stage III
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Import picture
Pressure Ulcer Staging Stage III
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Import picture
Pressure Ulcer Staging Stage III
Pressure Ulcer Staging Stage III
Pressure Ulcer Staging Stage IV
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Stage IV pressure ulcer is full
thickness tissue loss with exposed
bone, tendon, or muscle. Slough or
eschar may be present in the wound.
Undermining & tunneling are often
present in the wound
• Stage IV pressure ulcers can extend into
muscle or underlying supportive
structures making osteomyelitis possible
• Exposed bone/tendon is visible or
directly palpable
Stage IV
Stage IV Pressure Ulcer
Stage IV Pressure Ulcer
Stage IV Pressure Ulcer
Stage IV Pressure Ulcer
Staging: Unstageable
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Unstageable pressure ulcer is full
thickness loss in which the base of
the ulcer is covered by slough
(yellow, tan, gray, green, or brown)
and/or eschar (tan, brown, or black)
in the wound base
• Stable eschar (dry, adherent, intact
without erythema or fluctuance paint
with Betadine 1-2 times daily
• Soft mushy eschar requires
debridement
Unstageable
Pressure Ulcer Staging
Unstageable
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Import picture
Pressure Ulcer Staging
Unstageable
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Import picture
Staging: Unstageable
Staging: Unstageable
Staging: Suspected Deep Tissue
Injury
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Suspected DTI: is a purple or maroon localized
area of discolored intact skin or blood-filled
blister due to damage of underlying soft tissue
from pressure and/or shear. The area may be
preceded by tissue that is painful, firm, mushy,
boggy, warmer or cooler as compared to adjacent
tissue. May appear as deep bruise.
• Is difficult to detect in dark skin tones
• Evolution may include thin blister over a dark
wound bed
• The wound may further eveolve and become
covered by thin eschar
• Evolution may rapid exposing additional layers
of tissue even with optimal treatment
Deep Tissue Injury
Staging: Suspected Deep Tissue
Injury
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Import Picture
Staging: Suspected Deep Tissue
Injury
Staging: Suspected Deep Tissue
Injury
Staging: Suspected Deep Tissue
Injury
Staging: Suspected Deep Tissue
Injury
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Import Picture
Primary Causes of Pressure Ulcers
(Extrinsic Factors)
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Moisture Associated Skin Damage (MASD)
• Incontinence Associated Dermatitis (IAD) skin
inflammation associated with redness & itching
 Intervention: cleanser and skin barriers
• Intertrigo: superficial inflammation of 2 skin
surfaces or folds of skin--can be seen along
gluteal cleft leading to formation of pressure
ulcer or along breast or groin folds. Rash may
appear due to moisture (fungal and/or yeast)
 Intervention: skin cleanser
 skin protector
 dressing (Exudry)
 Intervention for rash:
• Periwound maceration caused by excessive
drainage
Moisture Associated Skin Damage
Caused by Diapers
Moisture Associated Skin Damage-Maceration
Moisture Associated Skin Damage-Maceration
Moisture Associated Skin
Damage—Rash Caused P.U.
Moisture Associated Skin
Damage—Rash
Moisture Associated Skin
Damage—Rash Caused P.U.
Charting: you might know what
you mean ….but does everyone
mean the same thing????
Case Study Mr. A.
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This is a 53 y.o. male admitted for
OD enucleation with constructive flap
and rectus muscle flap D/T maxillary
squamous cell carcinoma
Pt Hx: diabetes type 2, gout ,
hypertension, obesity &
hypercholoestermia
Case Study Mr. A.
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3/7/07 to OR
3/10/07 returned to OR:
reexploration of saphenous vein graft
D/T inability to auscultate the graft
Order written post-op: pt in sitting
position don not turn
Pt on Routine Bed 15 days without
turning and before specialty bed
could be placed
Case Study Mr. A.
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3/19/07 WOCN saw the patient
• Sacrum wound extending into the
coccyx and both buttocks measuring 14
x 17 x unk cms.
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The peri-wound tissue is red blanches in
some areas and extends circumferentially
around the wound 2-3cms
The majority of the wound bed is purple
blue non-blanchable with indurated red
areas along both medial buttocks (gluteal
cleft
Case Study Mr. A.
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Admission Lab:
• 3/7/07 Hgb: 9.8 Hct: 29 Glucose: 230
• 3/8/07 albumin: 1.9 Total Protein: 5.2
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Admission Braden:
•
•
•
•
•
•
Mobility
Activity
Nutrition
Friction & Shear
Sensory Perception
Moisture
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Total Score
1
1
3
1
3
3
12
Case Study Mr. A.
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Case Study Mr. A.
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Case Study Mr. A.
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Case Study Mr. A.
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Case Study Mr. A.
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Case Study Mr. A.
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Case Study Mr. A.
Case Study Mr. A.
Case Study Mr. A.
Case Study Mr. A.
Case Study Mr. A.
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Acronym for Skin Success
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S pecialty bed
K eep turning - Min Q2hrs
I ncontinence treat use skin barrier or
fecal containment devices and urine prop urinal
with males use condom cath’s
N utrition and fluids encourage
A ssess skin and Document
M oisturize skin
O rganize and Individualize care plan
R ecord & Report
E valuate outcome
Confused????