Posts Tagged ‘pressure ulcer’

Pressure Injury (Ulcer) Staging: More Real-World Answers

Friday, April 15th, 2016

More real-world wound care questions and answers relating to pressure injury staging, including slough, debridement and skin breakdown.

More Real-World Pressure Injuries

 

Can’t get enough of pressure injury staging? Neither can we. That’s why we’re excited to present even more questions and answers about this topic, based on what wound clinicians experience out in the field (versus what we might learn from textbooks or in a classroom).

In our first such post – packed with some awesome pressure injury staging questions from the field – we discussed slough, levels of destruction and debridement. Here, you’ll find out more about pressure injury staging as it relates to abrasions, surgical flaps, skin breakdown due to clothing, and more. So here they are – five more tips for staging pressure injuries, based on real questions from clinicians.

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Wound Care News: National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology

Wednesday, April 13th, 2016

Breaking Wound Care News

The term “pressure injury” replaces “pressure ulcer” in the National Pressure Ulcer Advisory Panel Pressure Injury Staging System, according to the NPUAP. The change in terminology more accurately describes pressure injuries to both intact and ulcerated skin. In the previous staging system Stage 1 and Deep Tissue Injury described injured intact skin, while the other stages described open ulcers. This led to confusion because the definitions for each of the stages referred to the injuries as “pressure ulcers”.

In addition to the change in terminology, Arabic numbers are now used in the names of the stages instead of Roman numerals. The term “suspected” has been removed from the Deep Tissue Injury diagnostic label. Additional pressure injury definitions agreed upon at the meeting included Medical Device Related Pressure Injury and Mucosal Membrane Pressure Injury.

CLICK HERE to read the National Pressure Ulcer Advisory Panel’s full press release.

 

 

 

Real World Pressure Ulcers: Staging Can Be Tricky

Tuesday, March 29th, 2016

This wound care Q&A answers five of the most common questions about pressure injury staging dilemmas (that you probably didn’t learn from textbooks).

Real World Pressure Injuries

 

In the world of wound care, just as in real life, the phrase, “Expect the unexpected” couldn’t be more appropriate. Clinicians can do everything exactly by the book, only to find that a wound just won’t heal, or the source of the problem appears to be one thing but then ends up being another. This is especially true with pressure injuries.

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What Stage Is It? Test Your Pressure Injury Staging Skills

Thursday, March 24th, 2016

(updated to reflect the 2016 NPUAP Staging Definitions)

How well do you know your guidelines for staging pressure injuries?  View the slideshow and test yourself!

Note: if you have any difficulties opening the slideshow, CLICK HERE to view it in SlideShare.

Test Your Pressure Injury Staging Skills from Wound Care Education Institute

 

 

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.

Wound Assessment: Skin of Many Colors

Thursday, February 25th, 2016

Understanding the structural differences between light and dark skin is crucial for clinicians, and this free Wild on Wounds webinar will help – plus you’ll get awesome tips for assessing skin of color.

- Cropped

 

Chances are that when you studied skin assessment in US textbooks, most of the case studies or featured photos involved patients with lighter skin tones – common to people of European decent.  Historically (and unfortunately), there’s been a lack of research, guidelines and consistency in treating skin of color.

This lack of diversity in educational resources is not only a disservice to clinicians and patients, it can be downright dangerous. For example, without exposure to proper techniques, you might not recognize a Stage I pressure ulcer in a darker-skinned patient, because non-blanchable erythema (redness) is harder to see.

As our patient population grows increasingly diverse, it is absolutely essential that bedside clinicians understand how skin differs among people of various ethnic and racial backgrounds, and what that means in wound assessment.

Learning starts here

Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS, WCEI Co-founder/ Clinical Instructor

Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS, WCEI Co-founder/ Clinical Instructor

The truth of the matter is that most of us have learned whatever we can about treating skin of color from our own experiences in the field. This is why WCEI Co-founder and Clinical Instructor

Nancy Morgan addressed this topic in her Wild on Wounds (WOW) 2015 National Conference presentation, “How to: Skin of Color.”

Now offered as an on-demand webinar, Morgan discusses the specific characteristics of skin of color, and how clinical conditions present differently in highly pigmented (versus lighter) skin. You can hear her entire presentation – and view it for free – with a special coupon code (listed below).

What makes skin darker?

Skin color is the result of melanin – a brown pigment. The purpose of melanin is to protect the skin by absorbing harmful ultraviolet (UV) radiation from the sun.  As we encounter UV rays, special cells called melanocytes produce additional melanin.

You may be surprised to learn that there’s no difference in the number of melanocytes between skin types. The palest and the darkest person will, on average, have the same number of these cells in their skin. However, the production and concentration of melanin in the epidermis (top layer of skin) is double in darker skin.

Does skin tone matter?

There are many skin tone classification scales used in the field, created mostly by and for dermatologists.  As Morgan states in her presentation, these scales aren’t helpful when it comes to wound care. “We have to do a very thorough visual inspection of the skin, and we have to talk to the patient about his or her baseline skin color.”

More webinar highlights

Besides exploring the basics of skin color and tone, you’ll find out more from Morgan’s webinar, including:

  • Skin conditions more common in darker skin, such as hyperpigmentation, keloid scarring, and xerosis.
  • Useful tips for performing a holistic assessment of a patient with dark skin.
  • Why some clinical conditions – such as sDTI, erythema or cyanosis – can be much more difficult to pick up in skin of color.
  • How other conditions, such as hemosiderin staining, may appear very different than they would in a patient with lighter skin.

Get your free webinarFree Webinar - Skin of Color

Are you ready to learn more about this topic and better address the wound care needs of your patients with dark skin?  Click here and use the code BLOG to access this 60-minute recording, which qualifies for an education credit.

More thoughts?

We’d love to know about your clinical experiences with skin of color: did you receive any official training regarding this topic, or have you mostly learned from your own personal experiences? Is your facility proactive in making sure clinicians are knowledgeable in how skin tone and color effect proper wound assessment? Tell us about your observations and experiences by leaving your comments below.

Wild on Wounds℠ (WOW) is the national wound conference designed for healthcare professionals that are interested in enhancing their knowledge in skin and wound management. Clinicians come from all over the US to see, touch and participate in our hands-on workshops. They also learn about all the new and advanced wound care treatments and technologies to better help care for their patients.  For more information visit www.woundseminar.com

News Flash: Document Education or Risk Facing Pressure Ulcer Citations

Thursday, December 17th, 2015

Failing to provide and document wound care educational efforts can lead to citations! Most recently, a facility was cited for not providing written documentation to a patient and his family about his Stage II pressure ulcer.

Document Education or Risk Citation

Wound care clinicians love to talk about wounds – preventing, treating and healing them. We love to compare notes, study photographs and learn about new techniques and strategies. But another vital piece of our job involves educating others, whether it be patients, family members or colleagues. Keeping everyone in the loop is essential to achieve the best outcomes, and avoid citations.

What it might look like now

Pressure Ulcer Staging Guide

Click for our FREE Pressure Ulcer Staging Guide

When we say that education must be a part of our pressure ulcer treatment and prevention program, we’re talking about routinely:

  • Providing printed information on the etiology of risk factors
  • Discussing the importance of risk and skin assessments
  • Explaining the role of support surfaces and the importance of positioning
  • Ensuring that each patient has a skin-care program individualized to meet their needs

These components of care are often accomplished during a staff in-service, or at care team meetings that focus on individual patients. But how are our patients and family members being educated on this issue?

Most clinicians would say that it is done by the individual licensed caregiver (often a nurse), as part of their normal daily activities on the unit.  The problem with this approach is that it’s not always documented, and often not very structured.  And this can lead to trouble.

What it must look like now

So what exactly are the expectations when it comes to pressure ulcer education according to today’s standards? Let’s consider what the 2014 International Guidelines for the Prevention and Treatment of Pressure Ulcers has to say about it.

In the section on implementing the guidelines, it speaks directly to patient consumers and their caregivers, and advises us to work with our healthcare teams and learn about pressure ulcer risk factors (and how this relates to their individual situation).  In order to meet this important objective, health care professionals must provide language appropriate printed materials, e-learning packages, and internet resources for the patient.

And where can you get such materials? Patient and consumer recommendation documents are currently being developed by the Guideline authors (we will let you know when they are available), but until then, one resource is MedlinePlus, where you can find the following patient handouts:

  • How to Care for Pressure Sores
  • Pressure Ulcer
  • Preventing Pressure Ulcers

No education? Hello, citation!

So besides the fact that a comprehensive pressure ulcer education program is crucial for better outcomes, failing to do so can lead to citations. All patient education, topics, methods, and responses must be documented.

Lesson learned?

The standards of care are always changing, and as wound care professionals, it’s critical to keep up with these changes. Do you and your facility currently meet these expectations when it comes to pressure ulcer education? How do you make sure patients and family members are not only being educated properly, but that these efforts are being documented as complete in the medical record? Please leave your thoughts or comments below.

Pressure Ulcers: Beyond the Risk Scales

Thursday, December 10th, 2015

When it comes to pressure ulcer prevention and treatment, traditional risk assessment tools don’t always tell the whole story. Find out what does.

Pressure Ulcer Risk Header

As wound care professionals, we know how pressure ulcers can negatively effect patients’ lives. This serious skin condition can not only lead to further complications and higher costs, but can also inhibit a patient’s ability to participate in rehabilitation and ultimately lead an active role in their community.

So the more we can do to properly assess pressure ulcers from the very beginning, the more we can do to help promote healing, reduce hospital stays and accelerate recovery time. Obviously, this involves the use of valuable tools, such as the Braden Scale. But we should also implement a good dose of clinical judgment once pressure ulcer risk is determined. Here’s how:

It’s more than just a Risk Score

The 2014 International Guidelines on the Prevention and Treatment of Pressure Ulcers stress the importance of looking at other factors, and not just the Risk Score when establishing risk levels and interventions for your patients. As mentioned earlier, in order to accurately determine your patient’s risk, the use of traditional tools alone (like the Braden Scale) is no longer considered to be enough.

Since the current condition of the skin is a key factor to consider when determining risk levels and interventions, the Guidelines recommend that both risk and skin assessments should be completed within eight hours of admission.  And anytime a risk assessment is completed, a skin assessment must be done and documented right along with it.  This applies throughout the patient’s stay within your care setting.

What else should you do?

When examining your patient’s chances for developing a pressure ulcer, taking note of their current skin condition is crucial. Are there reddened areas that barely blanch, and are they frequently recurring over the same boney prominence? Answering questions like these is important.

We must always look at the bigger picture of risk, and then factor in additional information such as psychosocial status, size, care setting, support surface, lab data and other sources. According to the National Pressure Ulcer Advisory Panel’s Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, risk factor assessment recommendations include:

  • Use a structured approach to risk assessment that includes assessment of activity/mobility and skin status.
  • Consider the impact of the following factors on an individual’s risk of pressure ulcer development: perfusion and oxygenation; poor nutritional status; and increased skin moisture.
  • Consider the potential impact of the following factors on an individual’s risk of pressure ulcer development: increased body temperature; advanced age; sensory perception; hematological measures and; general health status

In addition, the Reference Guide includes the following recommendations when conducting skin and tissue assessments:

  • In individuals at risk of pressure ulcers, conduct a comprehensive skin assessment: as soon as possible but within eight hours of admission (or first visit in community settings); as part of every risk assessment; ongoing based on the clinical setting and the individual’s degree of risk; and prior to the individual’s discharge.
  • Inspect skin for erythema in individuals identified as being at risk of pressure ulceration.
  • Include the following factors in every skin assessment: skin temperature; edema; and change in tissue consistency in relation to surrounding tissue.
  • Inspect the skin under and around medical devices at least twice daily for the signs of pressure-related injury on the surrounding tissue.

Are you on board?

Using your clinical judgment, along with traditional assessment tools, is a must when it comes to skin and risk assessment for pressure ulcers. We’d love to hear how you have learned to implement both within your facility. Have you noticed a difference in patient recovery? Do you think that this broader approach to assessment is well-known and practiced among your peers? Please leave your stories or comments below.

 

Floating Heels: More Than Just Pillow Talk

Friday, November 20th, 2015

The way you float the heels matters: new guidelines mean better patient care and lower risk of citations.

Floating Heels

When it comes to wound care, the term “float the heels” means that a patient’s heel should be positioned in such a way as to remove all contact between the heel and the bed. So given this context, is the following statement true or false?

Patients on support surfaces do not require their heels to be floated. 

If you guessed false, then give yourself a gold star. Yes, all patients at risk of breakdown, and those with pressure ulcers on the heel, must have their heels totally offloaded.  This requirement has not changed.

But here’s the catch – what has changed is the manner in which we should be accomplishing this.

Official Floating Heels Guidelines

Traditionally, the most common approach to floating the heels has been by placing pillows under the lower leg, positioned so as not to place pressure on the Achilles tendon and the heel.  Unfortunately, there has always been a problem with this method.

While you might position your patients perfectly in bed, with heels properly floated, the chances that they’ll remain perfectly still once you’re gone is slim to none. Patients naturally move and reposition themselves for comfort, which means upon returning, you will most likely find that the legs and heels are no longer in that same position.

This repositioning is a common occurrence, and leaves your patients vulnerable to the forces of friction, shear and pressure on the heel.  This traditional heel-floating technique often leads to unnecessary heel breakdown, and a failure to protect our patients properly. Additionally, facilities may be cited for floating Stage III heel ulcers on a pillow.

So what’s the official word on the subject? The 2014 International Guidelines on the Prevention and Treatment of Pressure Ulcers tell us that:

  • You can continue to float the heels with pillows under the full length of the calf for short-term use in alert and cooperative individuals.
  • For individuals with Stage I or II pressure ulcers on the heel, you can float the heels, or use a heel suspension device.
  • For individuals with Stage III, Stage IV or Unstageable pressure ulcers, heel suspension devices are strongly recommended.

What is a proper heel suspension device?

First of all, let’s talk about what a heel suspension device is not. A padded bootie (the kind we’ve used for years) simply doesn’t qualify.  Padding will never offload the tissues, it will only serve to somewhat cushion the skin.

What you do need is a lower leg boot specifically constructed to place the heel in a cup-like device that does not allow the heel any contact at all with any surface.   Patients can then reposition themselves in bed without fear of losing the pressure offload.  Some devices also have stabilization bars that can be used to prevent outward or inward rotation of the lower extremity.   When selecting a heel suspension device, it’s important to assess how much heat and humidity will be trapped on the skin underneath the boot.  This is a potential issue, since heat and humidity on the skin can predispose it to breakdown.

Is this a legal matter?

Wound care clinicians often ask if these revised techniques are lawfully required. The short answer is no, they are not. But – and it’s a big but -it is not uncommon for lawyers to refer to these guidelines in court, and question whether practices were in accordance with these standards.

So if you or your practice were subjected to such inquiries in a court setting, would you want your reply to be no? Of course not.  Citing ignorance when it comes to the change in heel-floating standards will not excuse wound care clinicians from the consequences.

Have you changed your practice to reflect these new guidelines? 

As responsible wound-care professionals, we know the use of heel suspension devices is the best way to offload.  And because current guidelines support this, if your practice hasn’t already done so, it’s time to implement them now.

Are heel suspension devices already used in your work setting? If so, have you seen a noticeable difference in patient care, compared to the traditional use of pillows and positioning? If not, do you have plans to foster change within your practice? We’re curious to hear your stories. Please leave your comments below.

Will the Real Pressure Ulcer Please Stand Up?

Wednesday, October 28th, 2015

How to know the difference between Incontinence Associated Dermatitis (IAD) and pressure injury.

IAD vs Pressure Injuries

 

As wound care clinicians, we treat our patients to the best of our ability and heal wounds – that’s what we do. But unfortunately, even under the best of circumstances, facility-acquired pressure injuries happen. And we have to document them … because again, that’s what we do.

So then it would stand to reason that no one would ever purposely document this type of pressure injury without cause, right? So here is the big question of the day: why is it that Incontinence Associated Dermatitis (IAD), rather than a pressure injury, is often documented as a Stage 2? We’ve got your answer.

The truth about pressure injuries and staging

We know that any staged skin lesion, by definition, is an area of skin disturbance caused by pressure, and according to the National Pressure Ulcer Advisory Panel, only pressure injuries should be staged. We also know that once any skin lesion is staged, you might find yourself sitting on the “hot seat” – having to defend how this new wound developed. And since part of our job is to prevent pressure injuries, staging areas like this puts us on the defensive when we don’t have to be.  The truth: unnecessary staging could lead to charges of inadequate assessment.

Let’s take a closer look

So how do we keep from putting ourselves in such an uncomfortable situation? First, let’s review the difference between these two types of lesions.

Incontinence Associated Dermatitis (IAD)

  • IAD is a form of Moisture Associated Skin Damage, and is defined as inflammation of the skin from prolonged exposure to urine and stool.
  • This is usually seen in conjunction with friction and/or chemical and/or bacterial factors – they work together to cause IAD.
  • The skin injury that results is always partial thickness in nature.
  • You may see some loss of epidermis and superficial dermis leading to a partial thickness wound, but these are not pressure injury.
  • These are moisture related injuries, and should never be staged.

Pressure Injuries

  • Pressure injuries are caused by unrelieved pressure or shearing forces (which is not what happens in the case of IAD).

Where it gets complicated

Even though we are talking about two different lesions, there are times when IAD converts to a pressure injury. Here’s what you need to know:

  • A previously identified IAD must be considered a pressure injury when you see new evidence of full thickness and damage below the dermis (slough, eschar, and granulation tissue are good examples).
  • This indicates that the deeper acting forces of pressure and shearing are present (read more about friction vs. shearing here).
  • You cannot damage the subcutaneous layer and below by moisture alone.
  • Remember – moisture damage to the skin can only be partial thickness.
  • Do you see evidence of full thickness injury? That means there was ischemic damage that took place and it’s no longer considered IAD, it’s considered a pressure injury. So it’s time to stage it and get to work healing it.

The importance of pressure injury risk assessment

Under such circumstances, this would be considered a facility acquired pressure injury.  Hopefully, your patient was previously identified as being at risk for pressure injury development, and prevention interventions are already in place.

Once staging happens, it’s time to go back and do another full assessment of your patient and the wound, and put in place both the proper treatment plan and more advanced prevention interventions. Moving forward, all incontinent patients should be considered at risk for skin breakdown. In other words, implement a care plan to prevent IAD and pressure injury from the get-go.

What do you think?

We’d appreciate hearing about your own experiences with staging IADs, versus true pressure injuries. Do all clinicians in your setting know how to tell the difference between these two types of wounds?  Do you feel you have adequate interventions in place for IAD patients?  And what are your biggest challenges in treating these patients and assuring proper identification? Please leave your comments below.

 

Lower Extremity Ulcers: Go With the Flow

Wednesday, October 21st, 2015

Lower Extremity Ulcer - Is this Pressure?

Imagine, if you will, the following scene: a wound care clinician is asked to weigh in on a lower extremity ulcer consultation, and upon arrival is told that it’s a pressure ulcer. So she seeks more information about blood flow:

Clinician #1: Tell me about the blood flow to the lower extremity.

Clinician #2: It seems okay because pulses are palpable on the foot.

Clinician #1: Are there recent Ankle Brachial Index (ABI) assessments in order to obtain a much more reliable assessment of blood flow?

Clinician #2: Um … no.

Here’s the truth

Unfortunately, this kind of conversation happens all the time, so let’s set the record straight: palpation of pulses is not a reliable assessment of blood flow to the foot. They can be misleading and leave you hanging – without the information you need to properly and safely manage the wound.  An ABI will reveal what you need to know about the blood flow to the lower extremity, and give you vital clues to the underlying disease process causing the ulcer. Only when this information has been gathered can you properly develop a plan of care that will help, and not hurt, the patient.

The 2014 International Pressure Ulcer Guidelines mentions performing a vascular assessment on every lower extremity ulcer.  That means, at a minimum, we need to check pulses and toe measurements, and perform an ABI. This will assist in identifying the true cause of the wound, whether it be pressure, venous, arterial, or mixed venous/arterial.

What’s this about an ABI?

An ABI is considered the gold standard of tests that can be easily performed at bedside – all you need is a blood pressure cuff and a hand-held Doppler. It is also the most useful test to assess lower extremity arterial perfusion, and compares the systolic blood pressure of the ankle to that of the arm (brachial). When should you perform ABI?

  • When pulses aren’t clearly palpable or are weak
  • On all patients with lower extremity ulcers
  • When the ulcer is not healing
  • Always before starting compression therapy

Compression therapy is the standard of care for the treatment of venous stasis ulcers.  ABI results will help identify significant arterial disease and determine the amount of compression (if any) that can be applied safely. You never want to compress a lower extremity that has significant arterial flow compromise, for fear of cutting off all blood flow and causing harm to your patient.

Blood flow assessment is a must

Earlier, we used the example of a patient who has a possible “pressure ulcer.” When we are not sure of the type of wound we are treating, we need to ask some serious questions:

  • Could there be arterial blood flow compromise that will make healing problematic or even unrealistic?
  • Is there venous disease complicating the clinical picture that could benefit from appropriate levels of compression?
  • Or is this strictly a pressure ulcer where the treatment plan will require off-loading interventions first and foremost?

The bottom line

When assessing a lower extremity ulcer, it is vital to determine the assessment of blood flow.  Without the information obtained from an ABI, your care plan can be inappropriate, your goal setting can be unrealistic, and your patient could be harmed.

What do you think?

We want to know about your experiences with this topic. When do you typically obtain an ABI in practice? In long-term care settings, how often do you obtain ABI measurements? If you’re not obtaining ABIs, what are you using? Please share your experiences below.