OASIS NP August 2011: Special Training. OASIS-C Integument Assessment. Rhonda Will, RN, BS, COS-C, HCS-D Assistant Director OASIS Competency Institute

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1 OASIS NP August 211: Special Training OASIS-C Integument Assessment Rhonda Will, RN, BS, COS-C, HCS-D Assistant Director OASIS Competency Institute 243 King Street, Suite 246 Northampton, MA Fax:

2 8/18/211 OASIS NP August 211: Special Training OASIS-C Integument Assessment Rhonda Will, RN, BS, COS-C, HCS-D Assistant Director, OASIS Competency Institute Skin Assessment Observe the skin at every assessment time point Temperature Color Moisture Turgor Integrity Wound type Etiology and history Wound Assessment A anatomic location S size S sinus tract, tunneling, fistulas, undermining E exudate S sepsis S surrounding skin M margins E erythema N necrotic tissue T tissue bed Baranoski, S., and Ayello, E.A. 1

3 8/18/211 OASIS Alert! Integument items are based on what you see AND are modified by CMS guidance for reporting findings Unavoidable Pressure Ulcer NPUAP March 21 Unavoidable - means that the individual developed a pressure ulcer even though the provider had evaluated the individual's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with individual needs goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. 2

4 8/18/211 NPUAP The National Pressure Ulcer Advisory Panel s recent consensus conference panelists agreed that patients who choose not to participate in their own pressure ulcer prevention could develop unavoidable pressure ulcers. They also agreed that there are clinical situations in which the development of pressure ulcers can be unavoidable. Press release 3/21 The NPUAP expert panel: Twenty-four multidisciplinary experts in pressure ulcer prevention and treatment comprised the voting panelists. Specialties included medicine, geriatrics, surgery, specialty nursing, physical therapy and dieticians. The international panel represented professional wound organizations, accrediting bodies, hospitals, rehabilitation agencies, long-term care, hospice, and home care. Unavoidable PU WOCN March 29 WOCN Position Paper: Avoidable versus Unavoidable Pressure Ulcers Pressure Ulcer Definition 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. 4 Stages + Suspected Deep Tissue Injury + Unstageable 3

5 8/18/211 Stage I NPUAP 27 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 II NPUAP 27 Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury Stage III NPUAP 27 Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. 4

6 8/18/211 Stage IV NPUAP 27 Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a stage IV 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. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Suspected Deep Tissue Injury (SDTI) Purple or maroon localized area of discolored intact skin OR a 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. (NPUAP 27) Suspected Deep Tissue Injury Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 5

7 8/18/211 Unstageable NPUAP 27 Full thickness tissue 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 bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. OASIS Alert! Unstageable pressure ulcers Pressure ulcer under a dressing or device that cannot be removed Full thickness tissue loss in which the true wound depth is obscured by slough and/or eschar in the wound bed Suspected deep tissue injury in evolution OASIS Alert! A previously stageable pressure ulcer now covered by eschar is considered unstageable 6

8 8/18/211 Pressure Ulcers Partial thickness tissue loss Involves epidermis and into but not through the dermis Superficial; presents as shallow crater, abrasion or blister Heals by epithelialization regeneration of epidermis across a wound surface Includes Stage I and II pressure ulcers OASIS Alerts! Stage II pressure ulcers that close/heal/fully epithelialize are not reportable on OASIS and therefore will not be newly epithelialized for data collection. Stage II pressure ulcers do not granulate and can only be not healing for data collection. Wound Primer: Definition Pressure Ulcers Full thickness tissue loss Penetrates through the fat (subcutaneous tissue) and may involve muscle, tendon, or bone Deep crater; may tunnel Heals by granulation, contraction and epithelialization Never considered fully healed Closed when fully granulated and covered with new epithelial tissue Includes Stage III and IV pressure ulcers 7

9 8/18/211 Degree/Status of Healing Pressure Ulcer Wound Status Not healing Early/partial granulation Fully granulating Newly epithelialized When epithelial tissue has completely covered the wound surface regardless of how long the pressure ulcer has been re-epithelialized. Wound Guidance Document WOCN Definitions Degree of Healing Not healing Wound with 25% avascular tissue (eschar and/or slough) OR Signs/symptoms of infection OR Clean but non-granulating wound bed OR Closed/hyperkeratotic wound edges OR Persistent failure to improve despite appropriate p comprehensive wound management Early/partial granulation 25% of the wound bed is covered with granulation tissue < 25% of the wound bed is covered with avascular tissue (eschar and/or slough) No signs or symptoms of infection Wound edges open WOCN Definitions Degree of Healing Fully granulating Wound bed filled with granulation tissue to the level of the surrounding skin No dead space No avascular tissue (eschar and/or slough) No signs or symptoms of infection Wound edges are open Newly epithelialized Wound bed completely covered with new epithelium No exudate No avascular tissue (eschar and/or slough) No signs or symptoms of infection 8

10 8/18/211 M136 Unhealed Pressure Ulcer Stage II or Higher Open Stage II Open or closed stage III or IV Unstageable M138 Current Number of Unhealed Pressure Ulcers/Stage Number of ulcers present on the day of assessment Number of ulcers in Column 1 that were also present at the most recent of SOC/ROC Patient 1 at SOC, has no unhealed Stage II Pressure Ulcer. There are no pressure ulcers. 9

11 8/18/211 Patient 1 at Follow up he has one Unhealed Stage II PU. 1 Patient 2 at SOC has one unhealed Stage III Pressure Ulcer. 1 Patient 2 at Follow-up, the Stage III PU has progressed to a Stage IV PU

12 8/18/211 Patient 3 at SOC has 1 unhealed Stage II PU. 1 Patient 3 at Discharge, the Stage II PU that was present at SOC has healed. A new Stage II PU developed and is present. 1 Patient 4 at SOC has 1 unhealed Stage II PU and one closed Stage III PU

13 8/18/211 Patient 4 at Discharge the Stage II PU that was present at SOC has healed. A new Stage II PU and the closed Stage III PU and is present Patient 5 at SOC has 1 unhealed Stage II PU, 1 unhealed Stage III PU and one closed Stage III PU. 1 2 Patient 5 at Discharge, the Stage II PU that was open at SOC has healed. A different Stage II PU is open in another location. The Stage III PU remains unhealed and the other Stage III PU remains closed

14 8/18/211 Patient 6 at SOC has 1 unhealed Stage II PU, 1 unhealed stage III PU and one closed Stage III PU. 1 2 Patient 6 at recert the Stage II PU that was open at SOC has fully reepithelialized. Another Stage II PU is open in a different location. The Stage III PU now has bone exposed and the other Stage III PU remains closed Patient 7 at SOC has 1 PU on the left heel covered with eschar and 1 blood filled blister on the right heel from pressure after many days of bed rest. There is a Stage III PU which closed in the hospital and remains closed

15 8/18/211 Patient 7 at recert the 1 PU on the left heel remains covered with eschar. The blood filled blister on the right heel has broken open and is now a Stage III PU. The Stage III PU which closed in the hospital remains closed now Patient 8 is bedbound. At SOC there is a skin graft on a Stage III PU with orders not to remove the pressure dressing until the physician's visit. There is a deep red, warm and boggy area noted on the right heel. 1 1 Patient 8 at discharge the skin graft on the Stage III PU has healed with some contracture and discoloration of the graft site and the deep red, warm and boggy area noted on the right heel is resolved

16 8/18/211 M131, M1312, M Unhealed Stage III or IV Pressure Ulcer with Largest Surface Dimension SOC/ROC/DC Consider all Stage III and IV pressure ulcers from M138 Col.1 row b (Stage III), row c (Stage IV), and row d.2 (unstageable covered w/ slough or eschar) M132 Status Most Problematic (Observable) Pressure Ulcer SOC/ROC/DC not healing is the only status for a Stage II newly epithelialized for Stage III or Stage IV M1322 Current Number of Stage I Pressure Ulcers 15

17 8/18/211 Upon inspection, the patient has one PU on the left heel that is covered with eschar. There is one Stage 3 PU on his sacrum. Granulation tissue is present in the wound bed with areas of slough scattered over 1% of the wound bed. M1324 Stage Most Problematic (Observable) Pressure Ulcer SOC/ROC/FU/DC In a multi pressure ulcer situation, consider an ulcer that is observable over one that is not. M137 Oldest Non-epithelialized Stage II Pressure Ulcer - DC Identifies: length of time a Stage II PU remained unhealed patients who developed Stage II PU while receiving care from the HHA. OASIS Alerts! Stasis ulcers are caused by inadequate venous circulation, are usually of the lower extremities, and are often associated with stasis dermatitis do not include arterial lesions or arterial ulcers Stasis ulcers that close/heal/fully epithelialize are not reportable on OASIS and will not be newly epithelialized for data collection. 16

18 8/18/211 M133 Does this patient have a Stasis Ulcer? Upon skin inspection the patient has one stasis ulcer under an Unna Boot M1332 determined Current by physician Number and patient report. of There is a physician s order not to change the dressing for 4 days. The other leg (Observable) has an exposed stasis Stasis ulcer with Ulcers beefy red granulation tissue filling 75% of the wound bed. Observable: Can be visualized; not covered by non-removable dressing or device. M1334 Status Most Problematic (Observable) Stasis Ulcer Do not use! Not a response option! Alert! A fully epithelialized stasis ulcer is healed and not reported in OASIS items! 17

19 8/18/211 OASIS Alert! Surgical Wound or a Scar? Surgical wound Unhealed wound resulting from a surgical procedure Scar Surgical wound that has been re-epithelialized (epidermal resurfacing across the entire wound surface) for approximately 3 days or more without dehiscence or signs of infection. How will you know when the 3 days begins? M134 Have a Surgical Wound? Unhealed wound resulting from a surgical procedure. Include: Stapled or sutured incisions Wounds/I&D with drain placement except ostomy Orthopedic pin sites Muscle flap, skin advancement flap, or rotational flap to surgically replace a pressure ulcer Excisions M134 Have a Surgical Wound? Include: A take down of a previous ostomy Central line sites Medi-port and port-a-cath sites and other implanted infusion devices (e.g. On-Q pump/q ball, etc.) and venous access devices regardless of functionality (AV shunt, peritoneal dialysis catheter) Shave, punch or excisional biopsy Arthrocentesis Left Ventricular Assist Device/HeartMate 18

20 8/18/211 M134 Have a Surgical Wound? Exclude: PICC line peripherally inserted and Peripheral IV Pressure ulcer treated with surgical debridement An existing wound treated by debridement or skin graft Old surgical wound with scar or keloid formation Ostomies even with drains (e.g. thoracostomy/chest tube, etc.) Cardiac catheterization and/or stent placement via a puncture with a needle Needle aspiration without drain placement Enterocutaneous fistula Retention suture with a button Callus removal Surgical Wounds Frequently heal by Primary Intention Wound edges are directly next to one another Little tissue loss, no granulation occurs Wound closure is performed with sutures, staples, or adhesive May heal by Secondary Intention Has area(s) of partial or complete wound separation or dehiscence Wound is allowed to granulate OASIS Alert! If there is any separation of the incision, then healing will be by secondary intention for data collection purposes. Surgical wounds healing by primary intention do not granulate and can only be not healing or newly epithelialized for data collection. A scar is not reportable for OASIS data collection. 19

21 8/18/211 The patient has a surgical wound with a dressing and an order not to change it until after the doctor s appointment in 3 days. There M134 is one other Have healing a surgical Surgical wound from Wound? a drain that was removed and now described as well approximated with some serous crusting. Report surgical wounds that are unhealed and have not become a scar; implanted venous access and infusion devices M1342 Status of Most Problematic (Observable) Surgical Wound Covered with new epithelial tissue < 3 days The patient had a hip replacement 4 weeks ago. One week ago M1342 the therapist Status noted that of the Most surgical Problematic wound completely reepithelialized without S/S of a complication. On this DC visit, the wound (Observable) is described as well Surgical approximated, Wound completely reepithelialized with no scabbing or S/S of infection. 2

22 8/18/211 Status of Healing Possible for OASIS Wound types Not healing Early/partial granulation Fully granulating Newly epithelialized Scar/healed and not reported on OASIS Stage 1 PU Stage 2 PU Stage 3 PU Stage 4 PU Closed Stage 3 or 4 PU Stasis ulcer Surgical Wound Primary Intention Surgical Wound Secondary Intention M135 Have a Skin Lesion or Open Wound Receiving Intervention Select YES : Clinical intervention: Other wound types (burns, diabetic ulcers, cellulitis, abscesses, wounds caused by trauma, etc) receiving clinical intervention On-going Non bowel clinical ostomies assessment receiving clinical or intervention per the treatment POC/485 (e.g., as cleansing, evidenced dressing by orders changes, etc) from the on home the health POCagency Select NO : pressure and stasis ulcers, surgical wounds; other types of skin lesions not receiving clinical intervention M225 POC Synopsis 21

23 8/18/211 M24 Intervention Synopsis Resources National Pressure Ulcer Advisory Panel Wound Ostomy Continence Nurses S. Baranoski and E.A. Ayello, Wound Care Essentials: Practice Principles, Wolters Kluwer Lippincott Williams &Wilkins, Second edition, 28 OASIS C Guidance Manual CMS OASIS Q and A NJHA New Jersey Hospital Association Created: November 24,

24 8/18/211 Wound Assessment & Management: Wound Care Fundamentals and OASIS-C BY MARY FARREN, RN, MSN, CWOCN, AND YANICK MARTELLY-KEBREAU, MSN, RN, CWOCN vol. 29 no. 4 April 211 Fazzi Associates, Inc. 243 King Street, Suite 243 Northampton, MA rwill@fazzi.com 23