Pressure Ulcer/Injury

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The National Pressure Ulcer Advisory Panel (NPUAP) held a consensus conference April 8–9, 2016 in Chicago, IL where numerous reforms to pressure ulcer-related terminology and definitions were decided. Most notably, it was decided the term pressure ulcer would now be known as pressure injury.

The NPUAP defines pressure injury as the following, “A pressure injury is localized damage to the skin and 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, co-morbidities and condition of the soft tissue.”

The term pressure injury does not mean the healthcare provider caused an injury to a patient, and it is not an indicator of poor care provided by nurses or other healthcare staff.


Blanchable Erythema

Blanchable Erythema- Reactive Hyperemia

Blanchable Erythema- Reactive Hyperemia

The picture above demonstrates Blanchable Erythema or Reactive Hyperemia, over a bony prominence, a dangerous sign in tissue that a pressure ulcer is imminent in formation. Reactive hyperemia as its name suggests is a reaction to pressure exerted on the body causing blockage of arteries. As a protective mechanism in the body, blood vessels dilate in the effected area to increase blood flow and deliver oxygen to the tissues. Blanchable erythema is red when it blanches, turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed. Tissue exhibiting blanchable erythema usually resumes its normal color within 24 hours and suffers no long-term damage. However, the longer it takes for tissue to recover from finger pressure, the higher the patient's risk for developing pressure ulcers. In dark-skinned patients, erythema is hard to discern. Use bright light and look for taut, shiny patches of skin with a purplish tinge. Also, assess carefully for localized heat, induration, or edema, which can be better indicators of ischemia than erythema.1 If detected early enough this condition can be treated with proper offloading and a pressure ulcer may be avoided. Topical agents and dressings are not needed in this condition. This is an important condition to note when performing skin assessments.


Stage 1 Pressure Injury

 

Stage 1 Pressure Ulcer

As defined by the NPUAP (1), a Stage 1 pressure injury (pictured above on the sacrococcyx) is:
Stage 1: Non-blanchable erythema
NPUAP Definition: A Stage 1 pressure  ulcer/injury  (pictured left) is: Intact skin with a localized area of  non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable  erythema  or  changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Consensus Treatment Recommendations from the SWC Physicians Group:
The management of a Stage 1 pressure injury can be challenging. It is imperative to initially get the right diagnosis. Our research indicates that 50% of nurses cannot conclusively differentiate between a Stage 1 Pressure Injury, Moisture Associated Skin Damage, Deep Tissue Pressure Injury, or a Skin Tear. Once the correct diagnosis is obtained bedside care is the most effective treatment for these wounds. The sites must be offloaded and the patients must be turned every 2 hours or even more often if needed. The wound area must be kept dry and free from moisture, heat, drainage, urine, and fecal matter. Intense scrubbing for cleansing can worsen the condition. Heavy application of thick adherent non transparent skin protectants such as Zinc Oxide can make it further difficult to monitor and cleanse the area. Application of hydrocolloid dressings can cause problems and should be monitored. Hydrocolloids can cause skin tearing when removed, they can increase moisture to the wound, and there can be a build up of material under the dressing. BCT Therapies (Balam Peru, Calmoseptine and Trypsin) combinations such as Granulex®, Vasolex®, and Xenaderm® demonstrate shorter healing times for ulcers treated with BCT ointment, but differences did not reach significance in one study, possibly because of the variability in reported treatment times.3 Topical skin barrier creams that are zinc based, dimethicone based, and petroleum are an option to prevent the wounds from being irritated by outside drainage and contaminants. Once again the removal of pressure from the area is the optimal treatment for this condition. If you must position the patient on this wound use direct foam padding dressings. Use great caution in caring for these wounds as they can rapidly deteriorate. 


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Stage 2

 

 

Stage 2 Pressure Ulcer

Stage 2 Pressure Ulcer

The above wound visibly shows dermis. As defined by the NPUAP, a Stage 2 pressure injury (pictured above) is:
Stage 2: Partial thickness
Partial-thickness loss of  skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or rupturedserum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.  This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).*Bruising indicates deep tissue injury.
Consensus Treatment Recommendations from the SWC Physicians Group:
In order to diagnose a Stage 2 pressure injury, the wound must be free of  necrosis, slough, and eschar. Since these are open wounds, their management and treatment differ from Stage 1 pressure injuries. Since these wound relate to pressure, the most important component of their care is to offload the sites and the patients must be turned every 2 hours or even more often if needed. The wound area must be kept dry and free from moisture, heat, drainage, urine, and fecal matter. Intense scrubbing for cleansing can worsen the condition. Application of hydrocolloid dressings can cause problems and should be monitored. Hydrocolloids can cause skin tearing when removed, they can increase moisture to the wound, and there can be a build up of material under the dressing. Once again the removal of pressure from the area is the optimal treatment for this condition. These wounds generally do not need active debridement. Common dressing choices include hydrogel dressings and others, that maintain a moist hydrating wound bed. Perform careful offloading at all times. If you must position the patient on this wound use direct foam padding dressings.

Stage 3

Stage 3 pressure ulcer

NPUAP Definition Stage 3 pressure/injury (pictured above, yellow tissue in the picture is fat) is:Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.  Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

SWC CLINICAL PEARL: The fat in these wounds may look like slough as pictured above. These wounds may have slough or eschar but minimally. Extensive slough or necrosis would be better defined as a Stage 4 Pressure Injury or Unstageable. If needed these wounds may be debrided, both surgically or with topical applications. The wounds should be covered with a moisture retentive dressing. Perform careful offloading at all times. If you must position the patient on this wound use direct foam padding dressings.


Stage 4

Stage 4 pressure ulcer

NPUAP Definition: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

SWC CLINICAL PEARL: The sacrococcyx wound pictured above is covered with slough, intertwined with areas of granulation tissue. There is visible exposed muscle and bone. The wound above should receive surgical debridement with possible addition of debriding agents. Wound healing will take significant time for these wounds and they should be managed very aggressively by a team of health care professional including a wound care specialist physician. Perform careful offloading at all times. If you must position the patient on this wound use direct foam padding dressings.


Deep Tissue Pressure Injury

Deep Tissue Injury

NPUAP  Definition: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.    Pain    and    temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.    The  wound  may  evolve  rapidly  to  reveal  the  actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue,  subcutaneous  tissue,  granulation  tissue,  fascia,  muscle  or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

SWC CLINICAL PEARL: In our time presenting the picture above to nursing staff strong arguments have occurred calling the wound above Unstageable or Stage 4, but it is a Deep Tissue Pressure Injury. The greatest area of confusion in this wound is that the skin is lifting in the central part of this wound. In a Deep Tissue Pressure Injury, the skin may or may not be intact per the NPUAP definition. These wounds are most commonly left intact and dry, with careful offloading at all times. If you must position the patient on this wound use direct foam padding dressings.

Remember as noted in the picture above: Blood Fluid Blisters are also considered Deep Tissue Pressure Injury.

 


Unstageable Pressure Injury

Unstageable wound

NPUAP Definition: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.  If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

SWC CLINICAL PEARL: This sacrococcyx wound above is covered with an eschar obscuring the actual depth of the wound. These wounds may or may not be debrided depending on clinical judgement. Frequently the eschar is not removed, the wound is kept dry, until there is further breakdown; reason being the eschar may be protective. Perform careful offloading at all times. If you must position the patient on this wound use direct foam padding dressings.


MEDICAL DEVICE RELATED PRESSURE INJURY

NPUAP Definition: Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

SWC CLINICAL PEARL: Frequently this type of wound is related to casts or oxygen tubing around the ears. Care should be taken to completely take the pressure off this injury to allow it to heal.


MUCOUS MEMBRANE PRESSURE INJURY

NPUAP Definition: Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

SWC CLINICAL PEARL: These wounds are generally found in the mucous membranes such as the intranasal cavity and may take on the shape of a device that may have caused the injury.


References

  1. Bardia Anvar. Mastery of Skin, Wound, and Ostomy Care. 2nd Edition 2017
  2. WOUND WATCH: Assessing pressure ulcers. LPN 2009. January/February 2009 Volume 5 Number 1 Pages 20-23.
  3. National Pressure Ulcer Advisory Panel. Pressure Ulcer Stages Revised by NPUAP/ February 2007.
  4. Narayanan S1, Van Vleet J, Strunk B, Ross RN, Gray M. Comparison of pressure ulcer treatments in long-term care facilities: clinical outcomes and impact on cost. J Wound Ostomy Continence Nurs. 2005 May-Jun;32(3):163-70.
  5. Doughty D, et al. Issues and challenges in staging of pressure ulcers. J Wound Ostomy Continence Nurs. 2006 Mar-Apr;33(2): 125-30
  6. Ankrom, et al. Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. Adv Skin Wound Care. 2005 Jan-Feb;18(1):35-42.

Links

www.npuap.org