Staging of Pressure Ulcers

                                         Suspected Deep Tissue Injury





When a pressure ulcer materializes it is graded based on he degree of tissue damage. The skin is made up of two respective layers which ae the epidermis and the dermis. The epidermis is the thin and tough outter layer of the skin. It contains no blood vessels and it can renew itself monthly. The dermis is the thick inner layer of the skin that is attached to the underlying tissue of the skin and provides the skin with strength and flexibility (Wound Care Information Network, n.d.).

The dermis layer of the skin consists of hair follicles. Its main function for the skin along with the hair follicles is to preserve fluid and electrolyte balance, protect from infections, sustain the body temperture,and to supply sensation (Wound Care Information Network, n.d.).

Stage I
In lighter toned people appears red and when pressed does not turn white. For darker toned people it may appear to be red, blue, or purple. This area of the skin can be painful, warm, and/or cooler than the surrounding skin.

Stage II
Is the partial thickness loss of the dermis. This outer layer of the skin will blister and/or form a shallow open area with the wound bed appearing to be red pink without slough. It can appeart to look like a blister.

StageIII
Is full thickness tissue loss. The tissue below is damaged with a sore that will look like a shallow crater. Subcutaneous tissue may be visible without seeing the bone, tendon, or muscle.

Stage IV
Appears with full thickness loss to the tissue. The crater is very deep. Deep enough to see bone, tendon, or muscle. Slough and eschar may also be visible.

Unstagable
Is full thickness tissue loss with the base of the ulcer covered with slough (yellow, tan, green, gray, or brown) or eschar that can appear to be black, tan , or brown. This stage of the pressure ulcer cannot be identified until the slough and/or eschar is removed.

Suspected Deep Tissue Injury
Is a localized area of the skin that is discolored and intact. It can appear as a blood filled blister related to the damage of the soft tissue underneath it from pressure and/or shearing.

References:

Wound Care Information Network (n.d.). Classifying or staging pressure ulcers. Retrieved from http://www.stoppain.org/pressureulcers/caregivers_staging.asp

Skin Safety & Prevention of Pressure Ulcers

A skin assessment should be performed for an inpatient based on a standardized skin and/or risk assessment tool such as the Braden scale. A full head to toe skin assessment should be carried out on every patient admitted into an acute care setting it in 6 hours of admission with a reassessment performed every 8-24 hours. A skin care policy and physicians consult should be implemented for skin care orders if a patient is found to be at risk of developing a pressure ulcer or if one already exist. A skin care policy (per facility) should consist of nursing interventions that will decrease or exclude friction, shearing, pressure, moisture, and adding maintenance of adequate nutrition and hydration (Institute of Clinical Systems Improvement, 2007).

All skin/risk assessments, their findings, and the initiation of a skin care policy plan should be documented utilizing a consistent documentation format (per facility). Skin/risk assessments, inspection findings, of the developments of a pressure ulcer should be communicated consistently along with any changes that may occur in the patients skin condition as soon as possible (Institute for Clinical Systems Improvement, 2007).

Reference:

Institute for Clinical Systems Improvement (2007). Skin safety protocol: Risk assessment and prevention of pressure ulcers. Retrieved from http://www.njha.com/qualityinstitute/pdf/226200833420PM63.pdf

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braden scale

How To Detrmine A Patients Risk Level for Pressure Ulcers

The Braden scale is an assessment tool used by healthcare professionals to assess a patients risk for the development of hospital acquired pressure ulcers. The evaluation of the Braden scale is based on six distinct indicators which are sensory perception, moisture, activity, mobility, nutrition, friction and/or shear. The Braden scale consists of six subscales that are scored fro 1-4 with total scores that has a range of 6-23. A Braden score of 15-18 signifies that the patient is at risk for developing a pressure ulcer, a score of 13-14 signifies that the patient is a a moderate risk for developing a pressure ulcer, a score of 10-12 indicates that the patient is at a high risk of developing a pressure ulcer, and a score less than or equal to 9 is an indication that the patient is at a very high risk of developing a presurre ulcer (Ayello, 2011).

Reference:

Ayello, E.A. (2011). Predicting pressure ulcer risk. Retrieved from http://consultgerin.org/uploads/File/trythis/try=this_s.pdf

Prevention and Management of Hospital Acquired Pressure Ulcers

A pressure ulcer is localized damage to the skin and/or the underlying tissue that primarily occurs over a bony prominence, as a direct effect of pressure, or the pressure mixed with shearing and/or friction (National Pressure Ulcer Advisory Panel, 2007).  Pressure ulcers are very painful, uncomfortable, and an expensive complication of being on bedrest.  In most cases pressure ulcers can be averted through proper identification of patients who are at risk along with appropriate use of preventive measures.  The frequency of hospital acquired pressure ulcers is a practical indicator of the quality of care given for inpatients (Perneger et al., 2000). 

Pressure ulcers characterize a very severe problem for patients in the acute care setting, and a very indicative care management challenge for clinicians.  Pressure ulcers primarily affect the elderly and patients that have impaired mobility.  As this population of patients continue to age the incidence of pressure ulcers are likely to increase (Garza et al., 2006).  The cost of treating a bedsore or pressure ulcer in a hospital setting averages right around $43,000 (WoundVision, 2011). 

As nurses we are in the position to be the first line of defense for the prevention and management of hospital acquired pressure ulcers.

References:

Garza, S., Okere, V., Igbinoba, J., Novosad, K., & Pexton, C. (2006). Six sigma and change management: Reducing hospital-acquired pressure ulcers. Retrieved from http://www.gehealthcare.com/euen/services/docs/Reducing_Hospital_Acquired_Pressure_Ulcers.pdf

National Pressure Ulcer Advisory Panel (2007). Pressure ulcer stages revised by NPUAP. Retrieved from http://www.npuap.org/pr2htm

Perneger, T.V., heliot, C., Rae, A.C., Borst, F., & Gaspoz, J.M. (2000). Retrieved from http//:archinte.ama-assn.org/cgi/reprint/158/17/1940.pdf

WoundVision (2011). Pressure ulcer, wound care, and healthcare statistics. Retrieved from http://woundvision.com/statistics