Pressure Injury in the Nursing Home

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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.


Deep Tissue Pressure Injury

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.

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.

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


Stage 1 Pressure Injury

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.
SWC CLINICAL PEARL: These wounds should be left intact without any debridement methods or breakdown. You must be very cautious in caring for these areas when washing the skin and protecting it. Care must be taken not to use friction when scrubbing. 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. Use great caution in caring for these wounds as they can rapidly deteriorate.


Stage 2 Pressure Injury

Stage 2 Pressure Ulcer

Stage 2 Pressure Ulcer

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.

SWC CLINICAL PEARL: These wounds should not have any devitalized tissue (necrosis or slough). This is a partial thickness injury and does not extend beyond the dermis. 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 Pressure Injury

NPUAP Definition Stage 3 pressure ulcer/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 Pressure Injury

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.


Unstageable Pressure Injury

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
Links:
www.npuap.org