Pressure Ulcer Awareness Program

1. Pressure Ulcer Awareness Program Prevalence and Incidence Evaluator Training

2. 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)

3. 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

4. Not all ulcers are pressure ulcers Neuropathic diabetic foot ulcer Pressure ulcer to heel Arterial ulcer on toes and forefoot Venous leg ulcer

5. 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. Deep Tissue Injury (DTI) Further description:Deep 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)

6. Differential Diagnosis for DTI • DTI may appear initially as a bruise but it connects as “cause and effect” to a pressure-related injury

7. 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. Stage I Further description:The 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)

8. 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 caregiver’s ring. HOWEVER, the redness in the coccyx area is related to pressure and is Stage I.

9. 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. Stage II Further description:Presents 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)

10. Stage II Differential Diagnosis • Appears as a blister with or without the skin intact.

11. 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. Stage III 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)

12. Stage III Differential Diagnosis • Deeper than a blister but not deep enough to go into muscle or down to bone.

13. 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. Stage IV 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)

14. 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.

15. 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 description:Until 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)

16. 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.