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- Tunneling – narrow passage way created by defect in fascial plane
- Undermining – Tissue under wound edge becomes eroded
- Bed texture and moisture
- assess after wound has been debrided and rinsed
- Pseudomonas – sickly sweet.
- W – wound or ulcer location
- O -odor
- U –ulcer category, stage or classification
- N –necrotic tissue
- D – dimensions and drainage
- P - pain
- I – induration (raised and hard)
- C -color
- T - tunneling
- U - undermining
- R - reddness
- E - edge
Prevelence of pressure ulcer
- Highest in acute care and long term care.
- Quadriplegia 60%
- Femoral Fracture 66%
- Tissue load caused by:
- ---Shear/ and exacerbated by moisture and temperature.
- medicare pays based on stage
New System – International NPUAP/EPUAP Pressure Ulcer Classification System
- Stage 1 – non blanchable erythema of intact skin. Area may be warmer, cooler, firmer, softer, compared to adjacent area.
- Stage II – superficial ulcer that presents as shallow crater without slough or bruising. May be ruptured, or intact (fluid or blood filled blister).
- ---Partial thickness ulcer involving epidermis, dermis, or both.
- Stage III – deep ulcer that presents as deep crater, may have undermining or tunneling.
- ---Full thickness skin loss involving the epidermis, dermis, and subcutaneous tissue. Bone/tendon are not visible or palpable.
- Stage IV – Deep ulcer with extensive necrosis, often has undermining or sinus tracts.
- ---Full thickness skin loss involving the epidermis, dermis, subcutaneous tissue, fascia, and underlying structures such as muscle, tendon, joint capsule or bone.
- Unstageable/Unclassified – a pressure ulcer should be described as unstageable if the base is obscured by eschar or slough.
- ---Full thickness
- ---Will be category III or IV
- Suspected deep tissue injury – local area of purple or maroon discoloration of intact skin or blood filled blister.
- ---Area may have been painful, firm, mushy, boggy, or warmer or cooler than surrounding tissue.
Pressure Ulcer Risk Factors
- - Decreased Mobility
- - Impaired Cognition
- - Poor Nutrition
- - Incontinence
- ---Impaired Sensation
- ---Advanced age
- ---Previous pressure ulcer
Pressure Ulcer Risk Assessment Tools
- Norton- 5 categories – physical condition, mental condition, activity, mobility, incontinence. Good/ slightly limited, lower scores mean higher risk
- Braden – lower score greater risk; used most often
- Gosnell- mental status, continence, mobility, activity, nutrition (1-5) higher score is greater risk.
PUSH- Pressure Ulcer Scale for Healing Score based on:
- Surface area
- Tissue type
- 7 point observational scale that describes wound and periwound.
- Higher scores mean more severe pressure ulcer
- Score of “0” means normal skin at risk
- One minute to complete.
Bates – Jenson Wound Assessment Tool - BWAT
- Includes 13 items describing wound and periwound characteristics, size, depth, edges, undermining, necrotic tissue amount, exudate (drainage) and amount, skin color, tissue edema, induration(hardening as a result of inflammation), granulation, epithelialization.
- 10 minutes to complete
- Valid and reliable
- Ability to respond to changes in ulcer status not yet assessed in literature.
- Recognize risk and intervene
- PT consult for:
- -------Blood sugar
- Wound care/ debridement, dressings, pulsed lavage, wound vac
- Recommend pressure reducing devices/wc cushions, specialty bed
- Positioning and positioning schedules
- NO DONUTS
- Exercise to strengthen patient to improve mobility/flexibility ex
- Functional training/transfers, gait
- Electrotherapy – electrical stimulation