Uncovering the Pressure Ulcer Coverup Rhonda Kistler RN MS CWON Wound Care Concepts Gentell
Objectives Identify the stages of pressure ulcer according to the depth of tissue destruction. Discuss the differences of healing between partial and full thickness ulcers. To be able to utilize the appropriate dressing for each stage of pressure ulcers and other wounds.
Impact Total cost of Nursing Home Care in 2010 $143.1 Billion Pressure Ulcer Costs $ 10.5 Billion to $17.8 billion in 2010 in the United States National Healthcare Quality Report May 2013
Impact 2.5 to 3 million people in the United States will develop a pressure ulcer each year A Pressure Ulcer can cost between $20,900 to $151,700 National Healthcare Quality Healthcare Report May 2013
Normal The largest organ Weighs 6 8 lbs Covers over 20 sq ft Thickness varies Thinnest eyelids Thickest sole of foot
Pressure Ulcer NPUAP Pressure Ulcer definition: 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.
Stage 1 Stage I: Non-blanchable erythema 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. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons.
Stage 1
Stage 2 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 or sero sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*.
Stage 2
Stage 2
Stage 3 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. The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers.
Stage 3
Stage 4 Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
Stage 4
How to measure undermining Head 12 Left 9 Right 3 Toes 6
Unstageable Unstageable/Unclassified: Full thickness skin or tissue loss depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. 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.
Unstageable
Unstageable
sdti Suspected Deep Tissue Injury depth unknown 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. 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.
sdti
Partial Thickness vs Full Thickness
Full Thickness Vascular ulcers Arterial Venous Diabetic/ Neuropathic ulcers
Vascular ulcers Arterial Venous
Diabetic/ Neuropathic
Partial Thickness Skin tears Incontinence Associated Dermatitis Tape Burns Maceration Excoriation
Partial Thickness Wounds
Partial thickness healing Partial thickness Fills in by epithelial resurfacing Occurs in 4 7 days No scar No change in skin appearance No loss of function
Partial thickness healing
Full Thickness Healing Slough/necrotic tissue may be present but must be removed before healing occurs Fills in with granulation tissue Forms a scar Possible loss of sensation or function Heals in 14 21 days
Full Thickness Healing
Full Thickness Healing
Full Thickness Healing Closed
Compare the healing
Moist wound healing Decades of extensive research into wound healing Cells migrate more rapidly in a moist environment than a dry one In 1948, and repeated in 1963 Research proved that Moist wounds healed 50% faster than dry wounds
F314 Determination of the need for a dressing for a Stage I or Stage II ulcer is based upon the individual practitioner s clinical judgment and facility protocols based upon current clinical standards of practice Current clinical practice indicates that Stage III and Stage IV ulcers should be covered For those pressure ulcers with significant exudate, management of the exudate is critical for healing
Characteristics of a ideal dressing Nontraumatic Maintains a moist environment Facilitates autolytic debridement Absorbs excess exudate Covers wound completely and appropriately Provides thermal insulation Provides a bacterial barrier Eliminate pain
Important considerations Availability Adaptability Durable Cost effectiveness Location Type of wound Exudate Size of wound Ease of application
Anatomy of a dressing Primary Therapeutic Next to the wound bed and meets the needs of the wound Secondary Protective Secures the primary in place and may assist in meeting the needs of the wound
Be a Label reader
What kind of Dressing is it? TRADE NAME Category/type
Categories of Dressings Alginate Antimicrobial Collagen Composite Contact Layer Foam Gauze Hydrocolloid Hydrogel Transparent Film Wound Fillers Other Treatment Modalities
Highly Absorbent Absorbs 20x its weight of exudate Biodegradeable dressing Non woven Manufactured from seaweed Frequency of change 1 x day Not to be used on dry wound beds Alginate
Alginate 3cc exudate Absorb to form a gel Easily washes out of a wound
Wounds
Antimicrobials To decrease bacterial load in wound Used in all wounds Comes in all forms Primary and/or Secondary dressings Frequency of change 1xday SILVER (Ag) Cadexomer Iodine Polyhexamethylene Biguanide (PHMB)
Antimicrobials
Wounds
Protein found in the body Absorbed into wound bed Stimulates granulation tissue Primary dressing Used in Partial or Full thickness wounds Used in minimal to moderate exudates Frequency of change 1 x day Collagen
Wounds
Nonadherent layer Allows exudate through Primary dressing Requires a secondary Frequency of change 1xwk Contact layer
Wounds
Composite Combines 2 or more products together in 1 dressing Bacterial Barrier Absorptive layer Nonadherent wound layer Waterproof layer Used on all wounds Primary and /or Secondary dressing Frequency of change 3x week
Porous texture Highly Absorptive Absorbs 20x weight in exudate Bacterial Barrier/ Insulator Border or nonborder Primary or Secondary dressing Frequency of change 3xwk Not for dry wounds Foam
Foam
Wounds
Gauze Permeable to bacteria Readily available Time consuming 2 4 x change Mechanical debridement Primary or Secondary dressing
F314 Some facilities may use wet to dry gauze dressings or irrigation with chemical solutions to remove slough. The use of wet to dry dressings or irrigations may be appropriate in limited circumstances, but repeated use may damage healthy granulation tissue in healing ulcers and may lead to excessive bleeding and increased resident pain. A facility should be able to show that its treatment protocols are based upon current standards of practice and are in accord with the facility s policies and procedures as developed with the medical director s review and approval.
Gelatin Pectin Carboxymethylcellulose Occulsive Semi occlusive Not for infected wounds Light to moderate exudate Available in multiple shapes sizes Pad, Powder, Paste, Semi Thick Liquid Frequency of change 2 3x week Hydrocolloid
Wounds
Water based gel Hydrates a dry wound Light exudate Primary dressing Requires a secondary dressing Frequency of change 1xday Tube, sheet, impregnated gauze Hydrogel
Wounds
Semi permeable Waterproof Allows for visualization Very light exudate Not for infected wounds Not for fragile skin Frequency of change 3xwk Transparent film
Fills in dead space Primary Dressing Requires a secondary Frequency of change 1xday Pastes, Powders, Gels, Foams Wound fillers
Other treatment modalities Negative Pressure Wound Therapy NPWT 4 layer Wrap E stim performed by P.T.
Strike through The point at which absorbed fluid reaches the outer surface or edge of a dressing
What kind of dressing?
What kind of dressing? Calcium alginate Hydrogel gauze Collagen Gauze Abd pads Foam
What kind of dressing?
What kind of dressing? Antimicrobial dressing Calcium alginate Hydrogel gauze Collagen Foam Composite
What kind of dressing?
What kind of dressing? Hydrocolloid Contact layer Hydrogel Collagen
What Kind of Dressing?
What kind of dressing? Calcium Alginate Rope Antimicrobial Collagen Foam Contact Layer Abd Pads
What kind of dressing?
What kind of dressing? Hydrocolloid Foam Hydrogel gauze Calcium alginate Transparent Film
2000 2010 Pressure Ulcers in 2000 were 13.9% Pressure Ulcers in 2010 10.4% Goal by 2019 is 7% National Healthcare Quality Report May 2013
THANK YOU
References NPUAP.org National Pressure Ulcer Advisory Panel website and library WOCN.org Wound Ostomy Continence Nurses Society website and image library Local Coverage Determination for Surgical Dressings L27222 retrieved from the world wide web 10/17/2012 F314 Procedures : 483.25c Pressure Sores Acute and Chronic Wounds Current Management Concepts 4 th Edition Ruth Byrant and Denise Nix 2013 Wound Care Essentials Practice Principles 3 rd Edition Sharon Baranoskiand Elizabeth Ayello 2012 Clinical Guide to Skin & Wound Care 7 th Edition, Cathy Thomas Hess 2013