Pressure Ulcer Staging. Staging of Wounds are based on the deepest level of tissue damage

Transcription

1 Pressure Ulcer Staging Staging of Wounds are based on the deepest level of tissue damage

2 Pressure Ulcer Staging

3 New Pressure Ulcer Staging Stage I Stage II Stage III Stage IV Unstageable Suspected Deep Tissue Injury

4 Pressure Ulcer Staging 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

5 Definition of a Pressure Ulcer 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

6 Pressure Ulcers Occur 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

7 Pressure Ulcer Measurement 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)

8 Document: Documentation Stage Pressure Ulcer Describe wound base color in % Describe drainage color, amount, presence of odor Describe surrounding tissue blanchability, color, s/s of infection

9 Pressure Ulcer: Stage I 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

10 Stage I

11 Pressure Ulcer Staging Stage I Import picture

12 Pressure Ulcer Staging Stage II 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)

13 Stage II

14 Pressure Ulcer Staging Stage II Import picture

15 Pressure Ulcer Staging Stage II

16 Pressure Ulcer Staging Stage III 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

17 Stage III

18 Pressure Ulcer Staging Stage III Import picture

19 Pressure Ulcer Staging Stage III Import picture

20 Pressure Ulcer Staging Stage III

21 Pressure Ulcer Staging Stage III

22 Pressure Ulcer Staging Stage IV 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

23 Stage IV

24 Stage IV Pressure Ulcer

25 Stage IV Pressure Ulcer

26 Stage IV Pressure Ulcer

27 Stage IV Pressure Ulcer

28 Staging: Unstageable 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

29 Unstageable

30 Pressure Ulcer Staging Import picture Unstageable

31 Pressure Ulcer Staging Import picture Unstageable

32 Staging: Unstageable

33 Staging: Unstageable

34 Staging: Suspected Deep Tissue Injury 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

35 Deep Tissue Injury

36 Staging: Suspected Deep Tissue Import Picture Injury

37 Staging: Suspected Deep Tissue Injury

38 Staging: Suspected Deep Tissue Injury

39 Staging: Suspected Deep Tissue Injury

40 Staging: Suspected Deep Tissue Import Picture Injury

41 Primary Causes of Pressure Ulcers (Extrinsic Factors) 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

42 Moisture Associated Skin Damage Caused by Diapers

43 Moisture Associated Skin Damage- -Maceration

44 Moisture Associated Skin Damage- -Maceration

45 Moisture Associated Skin Damage Rash Caused P.U.

46 Moisture Associated Skin Damage Rash

47 Moisture Associated Skin Damage Rash Caused P.U.

48 Charting: you might know what you mean.but does everyone mean the same thing????

49 Case Study Mr. A. 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

50 Case Study Mr. A. 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

51 Case Study Mr. A. 3/19/07 WOCN saw the patient Sacrum wound extending into the coccyx and both buttocks measuring 14 x 17 x unk cms. 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

52 Case Study Mr. A. Admission Lab: 3/7/07 Hgb: 9.8 Hct: 29 Glucose: 230 3/8/07 albumin: 1.9 Total Protein: 5.2 Admission Braden: Mobility 1 Activity 1 Nutrition 3 Friction & Shear 1 Sensory Perception 3 Moisture 3 Total Score 12

53 Case Study Mr. A.

54 Case Study Mr. A.

55 Case Study Mr. A.

56 Case Study Mr. A.

57 Case Study Mr. A.

58 Case Study Mr. A.

59 Case Study Mr. A.

60 Case Study Mr. A.

61 Case Study Mr. A.

62 Case Study Mr. A.

63 Case Study Mr. A.

64 Acronym for Skin Success 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

65 Confused????