Pressure Ulcer Awareness Program

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Pressure Ulcer Awareness Program

• Prevalence and Incidence Evaluator Training

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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.
• A number of contributing or confounding factors
  are also associated with pressure ulcers the
  significance of these factors is yet to be
  elucidated. (NPUAP, 2007)

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Tips

• A pressure ulcer is an ulcer related to some form
  of pressure and should not be confused with
  ulcers relating to disease (like cancer),
  vascular flow (venous or arterial) or neuropathy
  (like in persons with diabetes)
• You should be able to see a cause and effect
  relating to pressure with the ulcer.
• Redness or discoloration over a bony area related
  to sitting or lying
• Redness or discoloration on the skin related to
  pressure from a device such as a brace or a
  wheelchair pedal

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Not all ulcers are pressure ulcers
Neuropathic diabetic foot ulcer
Pressure ulcer to heel
Arterial ulcer on toes and forefoot
Venous leg ulcer
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Deep Tissue Injury (DTI)

• Description 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.

Further descriptionDeep 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. (NPUAP, 2007)
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Differential Diagnosis for DTI

• DTI may appear initially as a bruise but it
  connects as cause and effect to a
  pressure-related injury

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Stage I

• Description Intact skin with non-blancheable
  redness of a localized area usually over a bony
  prominence. Darkly pigmented skin may not have
  visible blanching its colour may differ from the
  surrounding area.

Further descriptionThe area may be painful,
firm, soft, warmer or cooler as compared to
adjacent tissue. Stage I may be difficult to
detect in individuals with dark skin tones. May
indicate "at risk" persons (a heralding sign of
risk). (NPUAP, 2007)
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Differential Diagnosis for Stage I

• Just a reddened area again look for the cause
  and effect relationship. Also when you press on
  the reddened area it does not blanche or look
  white it remains red.

Though we see a blister and a scratch, they are
both NOT caused by pressure. The blister is
actually directly related to friction with
turning, and the scratch is related to a
caregivers ring. HOWEVER, the redness in the
coccyx area is related to pressure and is Stage I.
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Stage II

• Description 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
  blister.

Further descriptionPresents as a shiny or dry
shallow ulcer without slough or bruising. This
stage should not be used to describe skin tears,
tape burns, perineal dermatitis, maceration or
excoriation. Bruising indicates suspected deep
tissue injury. (NPUAP, 2007)
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Stage II Differential Diagnosis

• Appears as a blister with or without the skin
  intact.

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Stage III

• Description Full-thickness tissue loss.
  Subcutaneous fat may be visible but bone, tendon
  or muscle is not exposed. Slough may be present
  but does not obscure the depth of tissue loss.
  May include undermining and tunneling.

Further description The depth of a Stage III
pressure ulcer varies by anatomical location. The
bridge of the nose, ear, occiput and malleolus do
not have subcutaneous tissue and Stage III ulcers
in these locations can be shallow. In contrast,
areas of significant adiposity can develop
extremely deep Stage III pressure ulcers.
Bone/tendon is not visible or directly palpable.
(NPUAP, 2007)
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Stage III Differential Diagnosis

• Deeper than a blister but not deep enough to go
  into muscle or down to bone.

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Stage IV

• Description Full-thickness tissue loss with
  exposed bone, tendon or muscle. Slough or eschar
  may be present on some parts of the wound bed.
  Often include undermining and tunneling.

Further description The depth of a Stage IV
pressure ulcer varies by anatomical location. The
bridge of the nose, ear, occiput and malleolus do
not have subcutaneous tissue and these ulcers can
be shallow. Stage IV ulcers can extend into
muscle and/or supporting structures (e.g.,
fascia, tendon or joint capsule) making
osteomyelitis possible. Exposed bone/tendon is
visible or directly palpable. (NPUAP, 2007)
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Stage IV Differential Diagnosis

• Should appear to have depth and go down into
  bone, tendon or muscle.

Young patient with spina bifida with Stage IV
pressure ulcer over coccyx area.
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Unstageable

• Description Full-thickness tissue loss in which
  the actual depth of the ulcer is completely
  obscured by slough (yellow, tan, grey, green or
  brown) and/or eschar (tan, brown or black) in the
  wound bed.

Further descriptionUntil enough slough and/or
eschar is removed to expose the base of the
wound, the true depth, and therefore stage,
cannot be determined. 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.
(NPUAP, 2007)
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Unstageable Differential Diagnosis

• Sometimes called Stage X because the evaluator
  cannot determine the depth due to necrotic tissue
  covering the ulcer. This can be either black
  (eschar) or yellow (yellow).

Necrotic ulcer, of unknown depth, created when
the one foot was left over the other, causing
pressure.