Archive for the ‘pressure ulcer staging’ Category

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.

 

Friction vs. Shearing in Wound Care: What’s the Difference?

Thursday, August 20th, 2015

Friction vs. Shearing: What's the Difference?

 

It’s a common question among wound care providers: what exactly is the difference between friction and shearing? These two conditions are common with limited mobility patients, and often contribute to the development of pressure ulcers. Knowing the answer to this question will help you provide better treatment for your patients. Plus, you’ll be able to amaze your friends at dinner parties! So in the interest of your patients and social life, we’ve got some answers.

What is friction?

Friction is when two forces rub together.  The result will be a superficial, partial thickness skin injury that will look like an abrasion.  For instance, a patient in bed might be agitated or restless, and as a result, continuously rub his feet across the sheets. No pressure is involved, his feet are simply sliding against the surface. This constant friction can cause the damage to the epidermis (and upper dermal skin layers) known as “sheet burn.”  The damage will be superficial in depth and irregular in shape. But this type of damage is not caused from pressure and therefore won’t be staged.

Friction can be avoided in this example by having the patient assist as much as possible when moving in bed, or using two caregivers and a lift sheet to avoid dragging across the bed.

What is shearing?

Shearing, on the other hand, is friction plus the force of gravity.  Let’s think of that same patient in bed, with his head in a raised position.

Example of a Stage 3 pressure injury, which can result from friction and shearing.

Example of a Stage 3 pressure injury, which can result from friction and shearing.

As the weight of gravity pulls down on the skeleton towards the foot of the bed, his skin might be stuck against the mattress due to friction. As his bones slide down, vessels in between the skin and the bone can become compressed, stretched and/or torn.  This causes a lack of blood flow to the tissue leading to ischemia. This is how we end up with a full thickness wound.

If pressure is present (and it almost always is with shearing), then it’s staged as a full thickness pressure injury. This is either a Stage 3 or 4, depending on the depth of tissue destruction, based on NPUAP definitions.  Have you seen a Stage 3 or Stage 4 pressure injury with an oblong or teardrop in shape,  irregular or jagged edges, and undermining or tunneling? This is a significant clue that shearing forces were present.

The Bottom Line

Remember this: it is not possible to have shear without friction, but it is possible to have friction without shear. Because shear is a result of a combination of friction and gravity, it can be avoided by keeping the head of the patient bed at a lower angle.

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.

 

How do I stage a wound if cartilage is present?

Monday, November 17th, 2014

(For the latest information based on the 2016 National Pressure Ulcer Advisory Panel Staging System, visit the 9/16/16 blog, “Pressure Injuries with Cartilage? Stage Away”)

In the human body the cartilage is found in joints, rib cage, ear, nose, bronchial tubes and between the inter-vertebral discs.

As wound clinicians we most often see Printcartilage just below the bridge of the nose or on the ear in our patients with pressure injuries.

Many clinicians continually question themselves how to stage a wound with visible or palpable cartilage present.

After all, cartilage does serve the same function as bone, but the word “cartilage” itself is not found in the stage IV definition from the National Pressure Ulcer Advisory Panel, or NPUAP. 

So how do you stage the pressure injury with visible or palpable cartilage?

Here is your answer: In August 2012, the NPUAP released a statement that stated: “Although the presence of visible or palpable cartilage at the base of a pressure injury was not included in the stage IV terminology; it is the opinion of the NPUAP that cartilage serves the same anatomical function as bone. Therefore, pressure injuries that have exposed cartilage should be classified as a stage IV.”

What that means is any pressure injury where you can see or feel cartilage will be classified as a stage IV pressure injury.

Simply put: if you have cartilage present in the wound, you stage it as a stage IV pressure injury.

Take our webinar, Staging and Identifying Pressure Injuries, or browse through all our webinars.  Use Coupon Code: BLOG.

I Stage, II Stage, III Stage , IV…. Making Pressure Ulcer Staging a Little Easier

Friday, June 6th, 2014

There has to be a way to get everyone on the same page.  You would think that over the last 6-7 years since the National Pressure Ulcer Advisory Panel (NPUAP) had released the updated staging guidelines we would have gotten better at this.  Not necessarily the case. blog
Lets try to make pressure ulcer staging as simple as possible.  We will take out the all the extra verbiage; you can read that later on.  We will break staging down to some user-friendly terms.  Now remember, we are talking about pressure ulcers, so all of these skin injuries pressure had to be present, sure – friction and shearing can contribute, but pressure must be present. They are usually located over a bony prominence but we know they don’t have to be; they will be located anywhere the skin has had unrelieved pressure.  If they are related to a device they will take on the shape of the device that has caused the injury to the skin.

Stage I.  This is an area of non-blanchable area of erythema (redness) of intact skin.  That’s what it is. Period.  Intact red skin.  Non-blanchable is when we push on the skin it stays red; it doesn’t turn white or blanch.  So, intact, non-blanchable area of erythema, a stage I pressure ulcer.

Stage II.  This is a superficial or shallow open area.  We say it is pink, partial and painful.  The damage is into the dermis here so the tissue we see will always be smooth pink/dark pink, not granulation tissue.  Never will we see any necrotic tissue here; your wound won’t have yellow, black brown colors in it.  It also may be an intact serum (clear fluid) blister. So there you have it; a stage II is a superficial open area with NO necrotic tissue or it can be an intact or ruptured serum filled blister.

Stage III. This stage is easy.  Damage is now into the subcutaneous tissue, but not through the subcutaneous layer.  So this is the start of full thickness tissue injury.  Now here is where we can start see slough, eschar, and granulation tissue in the wound bed.  Tunneling and undermining may also be present in the full thickness pressure ulcer.  In the stage III pressure ulcer we may see healthy subcutaneous tissue, necrotic tissue or granulation tissue.  What we WON’T see in the stage III is muscle, tendon, ligament or bone, ever.

Stage IV.  This is full thickness tissue damage where we now see muscle, tendon, ligament, or bone in the wound bed.  The definition also states “palpable” so if we can feel tendon or bone here, we would stage it as a stage IV.   Cartilage in the wound bed would be included in the stage IV pressure ulcer.  We can have granulation tissue or necrotic tissue present in the wound bed as well.  Undermining and tunneling may be present in a stage IV, but what I MUST see or feel are those underlying structures – muscle, tendon, ligament and / or bone present to say it’s a “stage IV”.

Unstageable pressure ulcer is a stage we use to classify the pressure ulcer that has enough necrotic tissue present to make the clinician uncertain whether the pressure ulcer is a stage III or stage IV.  So until enough necrotic tissue can be removed we place it in the “unstageable” category.  Once that necrotic tissue is removed and we can evaluate the actual level of tissue destruction in the wound bed, that is when we will stage it and it will either be a stage III or a stage IV.

Suspected Deep Tissue Injury (SDTI).  To be a SDTI the skin must be intact, it must be purple or maroon in color or an INTACT BLOOD filled blister.  Once this intact SDTI pressure ulcer opens up, we would then reclassify it based on our assessment or tissue type in the wound bed.

We need to use the staging definitions set out by the National Pressure Ulcer Advisory Panel (NPUAP) correctly, and all clinicians who assess skin need to have a good understanding of these definitions in order to properly stage pressure ulcers.  What was discussed about above is just a summary, there is more reading we need to do, but this will give us a good place to start with the staging.  We need to start staging consistently across the healthcare continuum; it really just comes down to good wound assessment skills, knowing the tissue type that lies before your eyes and identifying the level of tissue destruction and applying them to the NPUAP staging definitions. Lets get this right!