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Pressure Ulcer Inservice for Nurses
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St. John’s Hyperbaric and Wound Treatment Center
Lisa Hezel, RN WCC
Measuring and Staging Wounds
Measuring and Staging Wounds
Chronic refractory osteomyelitis of right heel
Plantar surface of the footCaused by pressure from a poorly fitting
shoe, patient is diabeticHow do we measure this wound?How do we stage this wound?
Measuring and Staging Wounds
Official Statement concerning this in-service!! This staging system was developed by the
NPUAP(National Pressure Ulcer Advisory Panel) and classifies only pressure ulcers based on anatomical depth of soft tissue damage.
Another system for diabetic foot ulcers only is called the Wagner system and is usually utilized by podiatrists. We will not cover that today.
Measuring and Staging Wounds
STAGE 1- An observable pressure related alteration of intact skin whose indicators may include one or more of the following: skin temperature (warmth or coolness) tissue consistency (firm or boggy) sensation (pain/itching) appears as defined area of persistent redness
in lightly pigmented skin, whereas in darker skin tones, this ulcer may appear with persistent red, blue or purple hues.
Measuring and Staging Wounds
Examples of Stage 1 Pressure Ulcers
Measuring and Staging Wounds
Stage 2-Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. Pink Partial Painful NEVER has slough,eschar or undermining
Measuring and Staging Wounds
Examples of Stage 2 Pressure Ulcers
Measuring and Staging Wounds
Stage 3- Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to but not through, underlying fascia.
The ulcer presents clinically as deep crater with or without undermining of adjacent tissue.
Measuring and Staging Wounds
Examples of Stage 3 pressure wounds.
Measuring and Staging Wounds
Stage IV—Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (ie. Tendon, joint capsule) Undermining and sinus tracts may be
associated w/ stage IV ulcers Can differentiate from stage III ulcers because it
will go PAST the Fascia
Measuring and Staging Wounds
Example of a stage IV woundPast the skin, subcutaneous level and goes to the
calcaneous bone
Measuring and Staging Wounds
Unstageable Pressure Ulcer—A pressure ulcer cannot be accurately staged until the deepest viable tissue layer is visible; this means that wounds covered w/ eschar &/or slough should be documented as unstageable.
EXCEPTION: In Longterm Care, the MDS form states that if a wound is covered w/ enough eschar/necrotic tissue which prevents adequate staging, then the code for that form will be a Stage IV pressure ulcer.
Measuring and Staging Wounds
Examples of Unstageable Pressure Ulcers.
Measuring and Staging Wounds
Deep Tissue Injury—describes a variation of pressure ulcers that appear initially as bruised or dark tissue. The location is the muscle bed or subcutaneous fat. The skin is usually intact at time of initial assessment. No Recognized diagnostic tools can identify pressure
related deep tissue injury under intact skin, therefore you must rely on visual inspection and palpation.
The area may be painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Measuring and Staging Wounds
Proposed Etiology of DTI— Pressure to the skin and soft tissue and
ischemia Muscle injury associated with a decrease in
nutrient supply Injury or damage to the fascia from shearing
injury or torsion of the perforating vessels
Measuring and Staging Wounds
Deep Tissue Injury--The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
DTI over a heel may look like a bruise or blood blister
Measuring and Staging Wounds
Classification Of Wounds Non pressure related wounds are classified as
either Partial or Full thickness. Venous Stasis Ulcers Skin Tears Burns
Measuring and Staging Wounds
Partial Thickness—destruction of the epidermis and dermis—You will never see slough in a partial thickness wound!
Measuring and Staging Wounds
Full Thickness—Destruction of epidermis and dermis, subcutaneous and or deeper.
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962006000600002&tlng=en&lng=en&nrm=iso
Measuring and Staging Wounds
Burns Superficial Superficial partial thickness Deep Partial Thickness Full Thickness
Measuring and Staging Wounds
Linear Style for Measuring wounds Length X Width X Depth Wound edge to wound edge in a straight line Consider the wound as a face of a clock—12
points to the patient’s head and 6 to the patient’s feet.
Measuring and Staging Wounds
Measuring on the foot using the clock system—Can be tricky! Just pretend your patient is a ballerina with her toes pointed and the heel will be 12:00 and the toes will be 6:00.
Measuring and Staging Wounds
To obtain measurements: Measure the longest from 12-6 on the clock and
3-9 on the clock. This keeps the measurements consistent from
week to week. When in doubt: draw a picture of what you
measured to make it easier for the next nurse!
Measuring and Staging Wounds
Depth—Distance from visible surface to the deepest area. Cotton tip applicator to the deepest portion of
the wound. Grasp the applicator w/ finger and thumb at the
point corresponding to the wounds margin. Withdraw from wound while maintaining
position of finger and thumb on the applicator. Measure from tip of applicator to position
against a centimeter ruler.
Measuring and Staging Wounds
Tunneling and Undermining—measure and document depth and direction. Use cotton tip applicator and gently probe around wound
edges in clockwise direction. Once tunneling/undermining have been identified, insert
applicator into that area. Grasp the applicator where it meets the wound edge w/
thumb and forefinger. Withdraw the applicator while maintaining the position of
the thumb and forefinger. Measure from the tip of the applicator to the position. Document based on a time on the clock ie. Tunneling at 1
o’clock measures 2 cm.
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