Critically Assessing Pressure Injuries

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1 Critically Assessing Injuries Copyright 2016 Gordian Medical, Inc. dba American Medical Technologies. LeadingAge Indiana presents FACULTY PAMELA SCARBOROUGH PT, DPT, CDE, CWS DIRECTOR OF PUBLIC POLICY & EDUCATION AMERICAN MEDICAL TECHNOLOGIES AMT Education Division Disclaimer The information presented herein is provided for the general well-being and benefit of the public, and is for educational and informational purposes only. It is for the attendees general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state. The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies shall not be liable for any errors or omissions in this information. Content of This Presentation 3 Top-down, bottom-up injuries NPUAP 2016 updated pressure Injury definition & staging descriptions The wound assessment Top-Down / Bottom-Up Skin Injuries Top-Down; Bottom-Up Concept of Skin Injury Accurate classification of wounds per etiology is critical Frequently challenging for bedside clinician Problem that we lack any diagnostic tool or imaging technology readily available for use by beside clinicians that would help distinguish between superficial and deep tissue injury Clinicians challenged to determine probably etiology based on Comprehensive wound assessment Patient history Mobility/activity Understanding of mechanisms of injury Top-Down Injuries Newer concept to describe superficial cutaneous injuries Versus bottom-up injuries such as pressure ulcers Injuries resulting from Mechanical forces Moisture and/or the effects of inflammation Friction Three most common Moisture associated skin damage (MASD) (moisture + friction) Medical adhesive related skin injury (MARSI) (stripping of skin s top layer) Skin tears Thayer DM, Rozenboom B, Baranoski S. Top-down Injuries, Prevention and Management of Moisture-Associated Skin Damage (MASD), Medical Adhesive- Related Skin Injury (MARSI) and Skin Tears. In: Doughty D, McNichol L. WOCN Core Curriculum, Wound Management. Chapter 17, Wolters Kluwer, American Medical Technologies. 1

2 Top-Down Skin Injuries Bottom-Up Skin Injuries Body Weight Top-down skin injuries Nonischemic wounds Usually develop due to superhydrated skin (incontinence, perspiration, maceration) in combination with friction Affect exposed surface of skin Other example of top-down skin damage Tape injuries (denuding) Excoriation (scratches) University of Chicago Ostomy Care Services Ischemic wounds caused by pressure or pressure in combination with shear Evidence indicates most ischemic wounds develop from bottom up Muscle layer more vulnerable to ischemia than the epidermis, dermis or subcutaneous tissue i.e. muscles requires the most oxygen to survive of any tissue in the body Therefore decreased perfusion from pressure will have greatest effect at muscle layer Skin Moving Most pressure/shear wounds are full-thickness injuries UP Undermining Surface Bone Moving Down Surface SHEAR Important Questions to Ask Oneself When Differentiating the Wound s Origin Is there evidence of ischemic damage, or significant tissue loss? Or 2016 Injury Updates National Ulcer Advisory Panel Does wound appear to have mechanical damage that disrupted superficial skin layers? National Ulcer Advisory Panel (NPUAP) National Ulcer Advisory Panel (NPUAP) is an independent not-for-profit professional organization dedicated to the prevention and management of pressure ulcers. Mission statement: NPUAP serves as the authoritative voice for improved patient outcomes in pressure injury prevention & treatment through public policy, education and research Think tank Has considerable influence on both clinical practice and CMS regulatory efforts for prevention and care of pressure injuries National Ulcer Consensus Meeting on Updates for Terminology & Staging Updated staging definitions presented at a meeting of over 400 professionals held in Chicago on April 8-9, Used consensus format lead by Dr. Mikel Gray from the University of Virginia who guided the Staging Task Force and meeting participants to consensus through an interactive discussion and voting process Participants also validated the new terminology using photographs American Medical Technologies. 2

3 Overview of Updates Additional 2016 Changes/Updates ulcer nomenclature change to pressure injury New definition for pressure injury Roman numerals (Stage I, II, III, IV) changed to Arabic numbers (1, 2, 3, 4) Adjusted staging definitions to be more accurate from an anatomical and tissue damage perspective Add clarifications to guide clinicians in differentiating the depths of tissue damage Added clarifications to differentiate other types of skin injury that look similar to, but are NOT pressure ulcers Term suspected has been removed from the Deep Tissue Injury diagnostic label Additional pressure injury definitions agreed upon Medical Device Related Injury Mucosal Membrane Injury How Do These Changes Apply to the Long-Term Care Setting from a Coding Perspective? These changes do NOT impact MDS Coding RAI Coding Instructions Nursing homes may adopt the NPUAP guidelines in their clinical practice and nursing documentation. However, since CMS has adapted the NPUAP guidelines for MDS purposes, the definitions do not perfectly correlate with each stage as described by NPUAP. Therefore, you cannot use the NPUAP definitions to code the MDS. You must code the MDS according to the instructions in this manual. What is the Purpose of Staging? To indicate the depth of tissue damage RAI language: ulcer staging is an assessment system that provides a description and classification based on anatomic depth of soft tissue damage. This tissue damage can be visible or palpable in the ulcer bed. ulcer staging also informs expectations for healing times. Definition of Ulcer vs Injury NPUAP RAI/MDS NPUAP Ulcer: A pressure ulcer is 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. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue. Clarification Was Needed Related to Ulcer and Injury Injury Replaces More accurately describes pressure injuries to both intact and ulcerated skin Previous staging system described Stage 1 and Deep Tissue Injury as injured intact skin while the other stages described open ulcers Confusion because definitions for each stage referred to the injuries as pressure ulcers. Ulcer American Medical Technologies. 3

4 RAI Instructions for Ulcer Coding vs NPUAP 2016 Injury Staging Definitions RAI-MDS, M-Section Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk) Stage 1 Injury: Nonblanchable Erythema of Intact Skin Intact skin with a localized area of non-blanchable Intact skin with a localized area of non-blanchable erythema, erythema, which may appear differently in darkly which may appear differently pigmented in darkly skin. Presence pigmented of blanchable skin. erythema or changes in sensation, temperature, or firmness Presence of blanchable erythema may precede or changes visual changes. in Color sensation, changes do not temperature, or firmness may include precede purple or visual maroon discoloration; changes. these Color may indicate deep tissue pressure injury changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury Rationale / Changes Replaced redness with erythema Added: Color changes do NOT include purple or maroon; as these indicate DTI. : None Stage 1 Injury with Edema Stage 2 Injury: Partial thickness Skin Loss with Exposed Dermis NPUAP 2016 Updates 2 2 Rationale / Changes 3 Partial-thickness loss of skin with exposed dermis. The wound Definition M0300B: Partial-thickness loss of skin with exposed dermis. Added: bed Partial is thickness viable, loss of pink dermis or presenting red, moist, The wound and bed may is viable, also pink present or red, moist, as and an Word exposed to dermis. intact as a shallow or ruptured open ulcer with serum-filled a red-pink may blister. also present Adipose as an intact (fat) or ruptured is not serumfilled blister. Adipose (fat) is not visible and Adipose (fat) is not visible, wound bed, without slough. May also granulation tissue, slough and visible present as and an intact deeper or open/ruptured tissues are deeper not tissues visible. are not Granulation visible. Granulation tissue, eschar are not present. tissue, These injuries commonly result slough blister. and eschar are not present. slough and These eschar are injuries not present. commonly These injuries from adverse microclimate and commonly result from adverse microclimate and result from adverse microclimate and shear in the skin over shear in the skin over the pelvis Further instructions from RAI: shear in the skin over the pelvis and shear in the and shear in the heel. the Examine pelvis the area and adjacent shear to or in the heel. This stage stage should should not be used not to describe Clarified: Do not use for surrounding an intact blister for moisture (MASD) MASD, IAD, Intertriginous, be used to describe moisture associated skin damage evidence of tissue damage. If other including incontinence associated dermatitis (IAD), medical adhesive related skin (MASD) conditions are including ruled out and incontinence the tissue intertriginous associated dermatitis (ITD), medical adhesive injury, or traumatic wounds (skin adjacent to, or surrounding the blister related skin injury (MARSI), or traumatic wounds tear, burn, abrasions). dermatitis (IAD), intertriginous MDS Impact: None as this is demonstrates signs of tissue damage, (skin tears, burns, abrasions). dermatitis not an anatomical or (e.g., color change, (ITD), tenderness, physiological change in a medical bogginess or adhesive firmness, warmth related or skin Stage 2. Additions should coolness) these characteristics suggest a improve coding and decrease injury suspected (MARSI), deep tissue injury (sdti) errors in documentation, or rather traumatic than a Stage wounds 2 (skin Ulcer. tears, especially with the added granulation not present. burns, abrasions). Stage 3 Injury: Injury: Full-thickness Skin Loss 2 2 Rationale / Changes 3 Full-thickness Definition M0300C: loss of skin, in which Full-thickness adipose loss of skin, (fat) in which is visible adipose (fat) in Adipose (fat) is visible and Full thickness tissue loss. Subcutaneous fat visible in the ulcer and granulation tissue and granulation, epibole (rolled the may be ulcer visible and but bone, granulation tendon or muscle tissue is and epibole (rolled wound epibole (rolled wound edges) are often present. edges) are often present edges) not exposed. are Slough often may be present. but Slough and/or eschar eschar may be may visible. The be depth Slough/eschar may be does not obscure the depth of tissue loss. visible; tunneling/um may of tissue damage varies by location; visible. May include The undermining depth or tunneling. of tissue damage areas of significant varies adiposity by anatomical be present, if it obscures can develop deep Coding Tips depth it is staged location; The depth of a areas Stage 3 pressure of significant ulcer varies adiposity wounds. Undermining can develop and tunneling deep may occur. Unstageable. by anatomical location. Stage 3 pressure Fascia, muscle, tendon, ligament, cartilage Added that fascia, wounds. ulcers can be shallow, Undermining particularly on and areas tunneling and/or bone may are not occur. exposed. Fascia, If slough or ligament, and cartilage that do not have subcutaneous tissue, such as eschar obscures the extent of tissue loss this is an along with bone muscle, muscle, the bridge of tendon, the nose, ear, ligament, occiput, and cartilage Unstageable and/or bone Injury. are not tendon are not present. exposed. malleolus. If slough or eschar In contrast, areas of significant adiposity can MDS Impact: None, as this is obscures develop extremely the deep extent Stage of 3 pressure tissue loss not an anatomical or ulcers. Therefore, observation and physiological change in a this assessment is an of unstageable skin folds should be part pressure of Stage 3 Stage 3. The descriptors pressure injury overall skin assessment. added should improve injury. with epibole Bone/tendon/muscle is not visible or (rolled edges) recognition, documentation, directly palpable in a Stage Copyright 3 pressure 2016 Gordian Medical, Inc. dba American Medical Technologies. and coding. ulcer. Stage 4 Injury: Full-thickness Skin and Tissue Loss 2 Rationale / Changes 2 3 M0300D: Full-thickness tissue skin loss and with tissue Full-thickness loss with skin and exposed tissue loss with or exposed exposed bone, tendon or muscle. Slough or or directly palpable fascia, muscle, tendon, eschar directly may be palpable present on some parts fascia, of muscle, ligament, cartilage tendon, or bone ligament, in the ulcer. Slough the wound bed. Often includes undermining and/or eschar may be visible. Epibole (rolled and cartilage tunneling. or bone in the ulcer. edges), Slough undermining and/or tunneling eschar often occur. Depth varies by anatomical location. If may be visible. Coding Tips Epibole (rolled slough or eschar edges), obscures undermining the extent of tissue The depth of a Stage 4 pressure ulcer loss this is an Unstageable Injury. varies and/or by anatomical tunneling location. The often bridge occur. Depth varies by of the nose, ear, occiput, and malleolus do not anatomical have subcutaneous location. tissue, and these If slough or eschar obscures Stage 4 the ulcers can be shallow. pressure injury extent Stage 4 pressure of tissue ulcers can loss extend this into is an Unstageable with light muscle and/or supporting structures (e.g., slough in fascia, Injury. tendon, or joint capsule) making Stage wound 4 base. osteomyelitis possible. Exposed bone/tendon/muscle is visible or directly palpable. Cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage 4. pressure injury with light slough in wound base. Added: Exposed or directly palpable: fascia, muscle, tendon, ligament, cartilage, or bone. Slough, eschar, epiboly, UM, tunnel may be present. Removed the shallow location statements- still present in RAI, see below. MDS Impact: None. Note this line in the RAI for Stage 4: The depth of a Stage 4 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. M0300E: Unstageable Ulcers Related to Non-removable Dressing/Device Only on RAI/MDS - Not part of NPUAP staging definitions DEFINITION NON-REMOVABLE DRESSING/ DEVICE Includes, for example, a primary surgical dressing that cannot be removed, an orthopedic device, or cast. Courtesy: Dot Weir American Medical Technologies. 4

5 Unstageable Injury - Obscured Full-thickness Skin & Tissue Loss M0300F: Full-thickness Unstageable skin Ulcer and Related tissue to loss Full-thickness in which skin the and extent tissue loss of in which tissue the extent of tissue damage within the ulcer damage Slough and/or within Escharthe ulcer cannot Known but not stageable due to cannot be be confirmed confirmed because because it is obscured it is obscured coverage of by wound slough bed or by slough eschar. by If slough slough or eschar. or eschar If slough is or eschar is removed, and/or eschar. a Stage 3 or Stage removed, 4 pressure a Stage injury 3 or Stage will 4 be pressure DEFINITIONS: injury will be revealed. Stable eschar (i.e. revealed. SLOUGH TISSUE Stable Non-viable eschar yellow, (i.e. dry, dry, adherent, adherent, intact intact without erythema without or tan, gray, green or brown tissue; erythema usually moist, can or be fluctuance) soft, stringy and on an fluctuance) ischemic on limb an ischemic or the limb heel(s) or the heel(s) should mucinous in not texture. be removed. Slough may be should not be removed. adherent to the base of the wound or present in clumps throughout the wound bed. ESCHAR TISSUE Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan Unstageable in color, Unstageable and may appear scab-like. Necrotic Injury tissue and eschar are usually due firmly to Eschar & Unstageable adherent to the base of the wound Unstageable Injury due to Injury and often the sides/ edges of Slough the Injury due due Eschar to Eschar wound. to Eschar & Slough 2 Rationale / Changes 3 Changed depth unknown to Obscured full-thickness skin and tissue loss Details that once the slough/eschar removed; a Stage 3 or Stage 4 will be revealed Comments about maintaining stable eschar remain, added ischemic limb or the heel(s) should not be removed MDS Impact: None as this is not a change in practice. It should improve awareness of full thickness nature of an Unstageable Injury. Deep Tissue Injury (DTPI): Persistent Non-blanchable Deep Red, Maroon or Purple Discoloration 2 Rationale / Changes Intact or non-intact skin with localized area of persistent nonblanchable deep red, maroon, purple Intact discoloration or non-intact skin with or localized Removed word suspected. 3 M0300G: Unstageable-Deep tissue: Suspected deep tissue area of persistent non-blanchable deep injury epidermal in evolution. separation revealing a dark red, maroon, wound purple bed discoloration or blood Changed from sdti to Deep or Tissue Injury (DTPI) DEFINITIONS filled blister. SUSPECTED Pain DEEP and TISSUE temperature INJURY epidermal change separation often revealing precede a dark Purple or maroon area of discolored intact skin due wound bed or blood filled blister. Pain Rationale: No other to skin damage color of underlying changes. soft tissue. Discoloration The area may may and appear temperature differently change often precede in diagnosis has suspected in be preceded by tissue that is painful, firm, mushy, skin color changes. Discoloration may the title. Many medical boggy, darkly warmer pigmented or cooler as compared skin. This to adjacent injury results appear differently from intense darkly pigmented and/or diagnostics are determined tissue. prolonged pressure and shear forces skin. at This the injury bone-muscle results from intense on signs and symptoms and Coding Tips and/or prolonged pressure and shear history; but are not titled interface. Once suspected The deep wound tissue injury may has opened evolve to rapidly forces at the to bone-muscle reveal interface. the The suspected. If, as in the case an ulcer, reclassify the ulcer into the appropriate wound may evolve rapidly to reveal the actual stage. Then extent code the of ulcer tissue for the injury, reclassified or may actual resolve extent of without tissue injury, tissue or may of any diagnosis, that stage. resolve without tissue loss. If necrotic determination was found to loss. Deep If tissue necrotic injury may tissue, be difficult subcutaneous to detect in tissue, granulation tissue, tissue, subcutaneous tissue, granulation be erroneous, the fascia, individuals muscle with dark or skin other tones. underlying structures tissue, fascia, muscle are or visible, other underlying this physician/extender and Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. structures are visible, this indicates a full indicates a full thickness pressure injury wound team should then When a lesion due to pressure presents with an thickness (Unstageable, pressure injury (Unstageable, Stage correct the wound type and 3 intact or Stage blister AND 4). the Do surrounding not use or adjacent DTPI to describe Stage 3 or Stage vascular, 4). Do not use DTPI to document rationale for that soft tissue does NOT have Copyright the characteristics 2016 Gordian Medical, of Inc. describe dba American vascular, Medical traumatic, Technologies. neuropathic, traumatic, deep tissue injury, neuropathic, do not code here. or dermatologic or dermatologic conditions. change. Deep Tissue Injury Examples Deep Tissue Injury in Evolution Medical Devices Related Injury 2 Rationale / Changes This definition describes an etiology. 3 This definition describes an etiology. Definition added to Medical device related pressure injuries result provide clear etiology Medical device related pressure injuries result to this type of pressure from the use of devices from designed the use of devices and designed applied and applied for for injury. diagnostic or therapeutic purposes. The It is still a Injury diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern and should be staged pressure injury generally according to the RAI or shape conforms of the device. to The the injury pattern should be staging guidelines. staged using the staging system. or shape of the device. The injury should be staged using the staging system. Bed pan medical device Bed pan related medical device pressure related injury pressure injury Courtesy: Dot Weir MDS Impact: None. However, this should improve recognition since these specific pressure injuries may not be on a typical boney prominence. Mucosal Membrane Injury (MPrI) What We DO NOT Stage 2008 definition (modified) using the word injury Mucosal Injuries (MPrI) are pressure injuries found on mucous membranes with a history of a medical device in use at the location of the ulcer. Since the mucosal membranes do not have the same anatomy; nor the same physiology of healing, they can NOT be staged. MDS impact: None. RAI Coding Tip: Oral Mucosal ulcers caused by pressure should not be coded in Section M. These ulcers are captured in item L0200C, Abnormal mouth tissue. Mucosal ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made. Shannon Rutledge BNurs, GradCert CritCareNurs, Tissue Viability Unit February 2015 Top-down injuries Moisture associated skin damage (MASD) Intertriginous dermatitis - Inflammation in skin folds MASD Peristomal MASD Maceration Incontinence Associated Dermatitis (IAD) American Medical Technologies. 5

6 What We DO NOT Stage What We Do Not Stage Medical adhesive related skin injury (MARSI)- term brought forward in 2012 Defined as an occurrence in which erythema and/or other manifestation of cutaneous abnormality including, but not limited to, vesicle, bulla, erosion or tear Common skin damage due to use of adhesive products particularly (but not exclusively) in institutional healthcare Denuding (adhesive removal over MASD) Skin Tears -International Skin Tear Advisory Panel Type 1: No skin loss Linear or flap tear that can be repositioned to cover the wound Type 2: Partial flap loss Type 3: Total flap loss Partial flap loss that can t Total flap loss exposing be repositioned to cover the entire wound bed wound bed What We DO NOT Stage Chronic wound etiologies other than pressure must have good wound differentiation skills to determine wound etiologies; All etiologies should be validated by the practitioner in the medical record Peripheral Arterial Disease (PAD) Venous Insufficiency Diabetic Neuropathic Foot Ulcer Lymphedema 34 The Injury Wound Assessment 35 Purpose of the Injury Wound Assessment Create a functional plan of care Follow CMS pressure ulcer documentation guidelines/mandates Track pressure ulcer healing/deterioration Communication between disciplines Communication with family Legal protection Mandated Weekly or Dressing Change Monitoring Classification/etiology Anatomic location Size Appearance of wound bed/base Wound Edges Drainage/Odor Pain, tenderness, itching 36 Copyright 2013 Gordian Medical, Inc. dba American Medical Technologies. American Medical Technologies. 6

7 37 Location Left trochanter and left iliac crest versus left hip. Left scapula versus left shoulder 38 Size = L x W x D Courtesy: Dot Weir Wound Measurement: Depth: Distance from visible surface to deepest point in wound base not covered with necrotic tissue 40 Wound Measurement Tunneling/Sinus Tract Insert moistened sterile cotton swab A pathway that may extend in any direction NOTE: Do not record depth if not able to see bottom of the wound bed/base. Use unstageable designation if PU. Tunnels Photos courtesy of Dot Weir Documenting Wound Characteristics Clinical Presentation of Tissue Types: Wound Base 41 Identifying Tissue Types Wound Bed Granulation tissue Full thickness/stage III PrUs Wound Edge/margins Slough New Epithelial tissue Partial thickness-stage II PrU Dermal tissue -note pink color-do not confuse with granulation tissue American Medical Technologies. 7

8 Clinical Presentation of Tissue Types: Wound Base Foreign object/exposed metal implant visible at base of wound Hypergranulation tissue extends above the wound edge MASD Wound Drainage Document: 1. AMOUNT scant, minimal, moderate, heavy or copious 2. COLOR & CONSISTENCY Serous - clear, watery plasma Sanguineous bloody (fresh bleeding) Serosanguineous - plasma and red blood cells Purulent - thick drainage (viscous), WBCs and living or dead organisms; may be yellow, green or brown 3. ODOR pungent, strong, foul, fecal, or musty 45 None Scant/small Moderate Large Exudate - Amount Copious Poorly managed exudate Courtesy: Dot Weir When was last dressing changed? Status None/Dry 46 Scant/ Small/ Minimal Moderate Large/ Heavy Copious/ Very Heavy QUANTIFYING WOUND EXUDATE Indicators: Based on a 24-hour observation period Wound bed is dry; there is no visible moisture and the primary dressing is unmarked; dressing may be adherent to wound. Small amounts of fluid are visible when the dressing is removed; the primary dressing may be marked up to 25%, but strikethrough (or saturation through the dressing) is not occurring; in many cases, this is the goal of exudate management. Wound bed glistens. Routine dressing changes fully control the exudate. Routine and appropriate dressing changes show that the drainage has met the dressing s absorptive ability without saturating or leakage; may cover 25%-75% of the dressing. Dressings are saturated with changes at routine intervals; exudate is uncontrolled and freely expressed. More than 75% of the dressing is covered by drainage. Adapted from the Association for the Advancement of Wound Care Quality of Care Wound Glossary 47 Color Edema Texture Indurated Fluctuance Temperature Epithelial Appendages 48 erythema, edema, Edema increased temperature. Erythema beyond 3cm Color Temperature suggesting potential infection. Structure & Quality Examination Edges Attached Unattached Epibloy Callus Examination American Medical Technologies. 8

9 49 Callus Epiboly around wound edge and with Epithelial into undermining periwound Islandsarea Texture Indurated Fluctuance Migrating Epithelial Edges Epithelial Appendages Edges Attached Unattached Epiboly Callus 50 Excoriation Macerated Structure Wound Edges and & Quality Area Denuded Examination Edges attached and flushed with wound Epiboly bed. (rolled edges) Examination Courtesy of Dot Weir Wound Related Pain Experiences Summary 51 Absence of manipulation May be continuous/intermittent 52 Tell us what you heard Periodic acute wound pain Regular repetitive treatments (i.e. dressing change) Provoked by more sporadic procedures (i.e. sharp debridement) References Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen.2000;8: Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, et al. Preparing the wound bed--debridement, bacterial balance, and moisture balance. Ostomy Wound Manage. 2000;46: Sibbald et al. Preparing the Wound Bed 2003: Focus on Infection and Inflammation. Ostomy Wound Management, 2003, 49(11), Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 2003;11 Suppl 1:S1 S Enoch S., Harding K. Wound Bed preparation: The Science Behind the Removal of Barriers to Healing. WOUNDS. 2003, 15: Schultz GS, Barillo DJ, Mozingo DW, Chin GA; Wound Bed Advisory Board Members. Wound bed preparation and a brief history of TIME. Int Wound J 2004;1(1): American Medical Technologies. 9

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