Pressure Ulcers
skin tear classification
Type 1 - No skin loss: linear tear or flap tear that can be repositioned to cover the wound bed Type 2 - Partial flap loss: partial flap loss that cannot be repositioned to cover the wound bed Type 3 - Total flap loss: total flap loss exposing entire wound bed
Location & risk factors
age Smoking Diabetes Mellitus Hypertension Dyslipidemia Obesity Family history of cardiovascular disease(2) Toes, dorsum of the foot, lateral malleolus, distal lower leg.(2)
Incontinence Associated Dermatitis (IAD)
A form of moisture-associated skin damage. Caused by prolonged exposure to urine, stool, or both that irritates the skin leading to erosion. Urine overhydrates exposed skin increasing the risk for friction injury Ammonia in urine elevates skin pH impairing its barrier function Fecal enzymes weaken epidermal integrity. Liquid stool is particularly irritating to the skin.
Venous Ulcer Definition
An open skin lesion of the leg or foot that occurs in an area affected by venous hypertension.
Blanch Test:
Apply light pressure. The skin should blanch or lighten. Release. The skin should return to normal color due to normal reactive hyperemia.
Classification System
Arterial ulcers are usually classified as partial thickness or full thickness wounds
pressure injuries
As discussed in Module 1, there is a history of pressure and/or shear exposure at the site of all pressure injuries If the deepest type of tissue is visible (or directly palpable), the pressure injury can be classified as Stage 1, 2, 3 or 4. If the deepest tissue is not visible, the pressure injury is classified as unstageable (i.e. deepest tissue obscured by slough or eschar); Deep Tissue Pressure Injury (DTPI) (i.e. deep red, maroon or purple discoloration); or Non-Visible (a special NDNQI category for pressure injuries under non-removable dressings or devices) Pressure injuries on mucosal membranes are counted, but not staged
Epithelialization
Epithelial cells migrate from the wound edge. Epithelial stem cells also migrate from any hair follicles that remain in the wound bed. Appears clinically along the wound edge as tissue that is thin, pearly, or silvery and shiny Newly epithelialized wound tissue appears pink/paler pink
Venous Ulcers Risk Factors for Lower Extremity Venous Disease (LEVD)
Family history Older age Obesity History of venous disease or thromboembolism Trauma to the legs Female Pregnancy an occupation that involves standing for a long period
Granulation
Fibroblasts migrate into the wound and produce new collagen and other extra-cellular matrix substances This tissue is highly vascular because of angiogenesis. It appears as beefy red tissue in the wound bed.
Angiogenesis
Formation of new capillaries to restore the vascular system
Medical Adhesive-Related Skin Injury (MARSI)
similar to medical device related pressure injuries, MARSI describes an etiology of injury. In the case of MARSI the etiology is trauma, not pressure. The FDA describes medical adhesive tape or adhesive bandages as "a device(s) intended for medical purposes that consists of a strip of fabric material or plastic, coated on one side with adhesive..." Elderly patients and neonates are at high risk for MARSI. MARSI can be prevented by careful selection of adhesive products, correct application and removal.
Classification Guidance
A healing pressure injury should be described according to the maximum anatomic depth it reached. A Stage 3 pressure injury that is healing should be described as a "healing Stage 3 pressure injury" Healing injuries should not be "reverse-staged" or "down-staged". A Stage 4 pressure injury cannot become a Stage 3, Stage 2, or Stage 1 pressure injury A healed pressure injury is not counted as a pressure injury. Following flap or graft repair of a Following flap or graft repair of a pressure injury, it is counted as a surgical site and not a pressure injury.
stage 1 pressure injury
A localized area of redness from pressure is observed over the right iliac crest of an elder male patient. The skin surface is intact. The reddened area of skin is nonblanchable.
What is a pressure ulcer?
A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to medical or other devices. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue.1
Moisture-Associated Skin Damage(MASD)
A term used to describe skin conditions that are the result of exposure to moisture. Defined as inflammation of the skin and erosion from prolonged exposure to moisture and its contents. Common sources of moisture include urine and stool, perspiration, wound exudate, and effluent from an ostomy.
Intertriginous Dermatitis (ITD)
A type of MASD caused by trapped perspiration and frictional forces between two opposing skin folds. Areas commonly affected include axillary, inframammary and inguinal skin folds. Obese patients are at higher risk with ITD frequently found in neck folds, under pendulous breasts and under the abdominal or pubic panniculi. Secondary infections (especially Candida albicans) may develop. Intertriginous dermatitis in the axilla of an obese woman.
arterial ulcers
A wound caused by impaired arterial blood flow to the lower leg and foot. The impairment in blood flow results in tissue ischemia, necrosis, and loss.
Skin Tears
A wound caused by shear, friction, and/or blunt force resulting in the separation of skin layers.
Diabetic Foot Ulcers
A wound on the foot of a person with diabetes.
skin tears causes
Blunt trauma from accidently bumping into objects Friction/shear injury or mechanical trauma during provision of ADLs Transfers and falls Equipment related injury
Location of the Incontinence-Associated Dermatitis (IAD)
Buttocks, perineum, perianal area - may extend to inner and posterior thighs
Wound contraction
Collagen fibers and extra-cellular matrix contract Seen clinically as a reduction in wound depth and size
Location
CommCommon sites - toe interphalangeal joint, metatarsal head, plantar surface of the foot, under heel
Associated Skin Assessment
Cooler skin temperature Thin, shiny skin Decreased or absent skin hair Decreased pulse strength in affected extremity Skin pallor on foot elevation; dusky rubor on dependency Dystrophic toenails Low Ankle-Brachial Index (ABI)
Anatomic Distribution
DTPI most commonly occur on heels (29-41%), sacrum (19-40%) and buttocks (7-13%).
Associated Skin Assesssment for foot ulcers
Decreased sensation in the foot (Loss of protective sensation with monofilament testing) The warm skin may be dry Callus formation, skin cracks, and fissures Abnormal toenail growth Plantar fat pad atrophy Foot deformities such as hammer toe, claw toe, and Charcot's foot
Wound Characteristics for a foot ulcer
Depth varies from partial thickness to full thickness with bone involvement Regular wound margins OfteOften surrounded by a rim of calloused tissue Low to moderate amount of drainage Assess for signs of inflammation and infection Suspect osteomyelitis if the bone is visible or directly palpable.
Other names for Incontinence-Associated
Dermatitis have included Perineal Dermatitis, Diaper/Napkin/Nappy Dermatitis or Rash, Irritant Dermatitis and Moisture Lesions.
Associated Skin Assessment for the Incontinence-Associated Dermatitis (IAD)
Diffuse erythema of the skin surface Erythema is brighter red in persons with lighter skin tones Erythema is subtle red in persons with darker skin tones Edema may be present Areas of skin maceration may be observed Secondary cutaneous infection Irritated/impaired skin is more easily invaded by microorganisms A secondary fungal infection (from Candida Albicans) is seen as a maculopapular rash with satellite lesions
Best Model for Prediction in Older Hospitalized Patients
Ecchymosis (bruising) Senile purpura Hematoma Evidence of previously healed skin tear Edema Inability to position oneself independently
Stage 3 Pressure Injury: Full-Thickness Skin Loss
Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. UnderminingSubmit and tunnelingSubmit may occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
unstageable Pressure Injury: Obscured Full-Thickness Skin and Tissue Loss
Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed.1
Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss
Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer Slough and/or eschar may be visible. Epibole (rolled edges), underminingSubmit and/or tunnelingSubmit often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury
Associated Skin Assessment
Hyperpigmentation of lower calf and ankle skin from hemosiderin staining (leakage of red blood cells into the tissue) Lipodermatosclerosis - thickening and fibrosis of the skin and subcutaneous tissue from chronic inflammation Edema that may worsen with prolonged standing Dry scaly skin that may be itchy Weepy skin Evidence of healed venous ulcers
Classification System for the Incontinence-Associated Dermatitis (IAD)
Incontinence-Associated Dermatitis Intervention Tool Incontinence-Associated Dermatitis Severity (IADS) Instrument Body location of incontinence-associated dermatitis Magnitude of erythema Presence or absence of skin erosion Presence or absence of skin rash IAD Severity Categorization Tool
A skin tear can be:
Partial Thickness (separation of the epidermis from the dermis) OR Full Thickness (separation of both epidermis and dermis from underlying structures)
Deep Tissue Pressure Injury (DTPI)
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.1
Stage 1 Pressure Injury
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.1
Risk Factors - Extrinsic
Long-term corticosteroid use Polypharmacy Dry skin from frequent bathing and/or use of skin cleansers that reduce natural skin oils Medical equipment and assistive devices Removal of tape or dressings
Diabetic Foot Ulcers Causes
Lower Extremity Neuropathic Disease (LEND) (peripheral neuropathy) Sensory neuropathy leads to loss of protective sensation Motor neuropathy causes an imbalance between flexor and extensor muscles leading to foot deformities that create abnormal bony prominences and pressure points Autonomic neuropathy alters blood flow in the foot and sweat and oil gland function leaving skin dry Peripheral vascular disease with poor microvascular circulation Leads to tissue ischemia Repetitive mechanical stress or excessive pressure Less well noticed or not noticed because of sensory neuropathy Poorly controlled blood glucose levels Accelerates the development of arterial disease
Location
Lower calf and ankle (the gaiter area) Pretibial and medial supra-malleolar area of the ankle near perforator veins.
The types of skin injuries caused by medical adhesives include:
Mechanical trauma Epidermal stripping Tension injury or blister Skin tear Dermatitis Irritant contact dermatitis Allergic dermatitis Other Maceration from trapped moisture Folliculitis
Arterial Ulcers causes
Most commonly - Atherosclerosis Arteriosclerosis History of arterial insufficiency to lower extremities: Peripheral Arterial Disease (PAD) Lower Extremity Arterial Disease
Location of the skin tears
Most commonly - upper and lower extremities Other body areas: head and trunk
NonBlanchable Erythema
Nonblanchable erythema is a defined area of redness that persists (does not blanch/become pale) when pressure is applied to the area.
Usual Bony Prominences
Occiput Ear Scapula Spinous Process Shoulder Elbow Iliac Crest Sacrum/Coccyx Ischial Tuberosity Trochanter Knee Malleolus Heel Toe
Stage 2 Pressure Injury: Partial-Thickness Skin Loss with Exposed Dermis
Partial thickness loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Risk Profile
Patients with a DTPI are usually older, sicker and more likely to be hospitalized in a critical care or surgical unit. Often, a precipitating event involving "intense and/or prolonged pressure and shear forces" can be identified 48-72 hours before DTPI discovery. Precipitating events include "found down" on a hard surface, prolonged surgery or procedural time, and periods of hemodynamic instability.
Pathophysiology
Prolonged venous hypertension results in vein wall damage. This increases capillary permeability and allows the extravasation of micromolecules and macromolecules into the surrounding tissue. Damage to these tissues leads to venous ulcer development.
Characteristics of Arterial Ulcer
Round and regular in shape Pale wound bed Can be shallow in depth or relatively deep Smooth wound edges Gangrenous/necrotic tissue may cover the wound Minimal drainage Severe pain
Healing Process - Full Thickness Pressure Injuries
The healing of full-thickness wounds occurs in phases. Inflammation Phase Proliferation Phase Maturation Phase (also called Remodeling Phase) During the Inflammatory Phase, hemostasis is established. Neutrophils and macrophages migrate to the wound to remove bacteria, devitalized tissue, and other debris. Cytokines released during this phase promote cell proliferation and the synthesis of extracellular matrix molecules important to processes in the proliferation phase.
Healing Process - Partial Thickness Pressure Injuries
The healing of partial thickness wounds occurs predominantly through re-epithelialization.
Classification Systems
The most commonly used diabetic foot ulcer classifications systems are: Meggit-Wagner Classification System Grade 0 - Healed or pre-ulcerative wound Grade 1 - Superficial ulcer without penetrating to deeper layers Grade 2 - Deeper ulcer extends to tendon, bone or joint Grade 3 - Deep tissues involved with abscess, osteomyelitis or tendinitis Grade 4 - Limited gangrene (part of the foot) Grade 5 - Extensive gangrene (whole foot) University of Texas Diabetic Wound Classification System Stage A to D based on infection and ischemia Grade 0 to 3 based on ulcer depth
Mucosal Membrane Pressure Injuries
The mucous membrane is the moist lining of body cavities including the mouth and nasal passages. In some places, mucous membranes are contiguous with skin like at the lip and nares. These locations require careful differentiation of the type of tissue before determining the presence of a mucosal membrane pressure injury. The pressure injury classification system cannot be used to categorize/stage mucosal pressure ulcers because the histology of the mucous membrane is different from skin. Nonblanchable erythema cannot be seen in mucous membranes It is difficult to distinguish between superficial tissue loss and deeper full thickness ulcers Soft coagulum seen in mucosal pressure injuries which looks like slough, is actually soft blood clot Exposed muscle would seldom be seen Bone is not present in mucous membrane tissue
Prevalence
The percent of pressure injuries classified as DTPI varies depending on the setting and study design. Generally 9-12% of pressure injuries are DTPIs, but between 1 and 2% of patients are affected by DTP.
Associated Skin Assessment in Older Adults
Thin skin appearance due to changes associated with aging Epidermal thinning Decreased dermal thickness Subcutaneous tissue loss Decreased skin elasticity and tensile strength Surrounding purpura or ecchymosis
Incontinence-Associated Dermatitis (IAD) Risk Factors
Types of incontinence Urinary Fecal Double Frequent episodes of incontinences (especially fecal) Use of occlusive containment products Poor skin condition (due to age, steroids, diabetes) Compromised mobility Diminished cognitive awareness Inability to perform personal hygiene Pain Elevated body temperature Medications (antibiotic, immunosuppressant) Poor nutritional status Critical illness
Wound Characteristics
Typically shallow in depth Irregular in shape Defined wound edge Moderate to a large amount of drainage is common Often has a yellow fibrous film covering the surface Variable pain (mild to severe)
Classification System
Usually classified as partial thickness or full thickness wounds
Incontinence-Associated Dermatitis (IAD) Wound Characteristics
Usually partial thickness skin loss Ranges from one or more islands of erosion to extensive denudation of the epidermis and dermis Skin breakdown may include, denuded skin, skin erosions, vesicles, bullae Epidermal damage of different depths Red, but skin intact (mild) Red with skin breakdown (moderate to severe) Irregular and indistinct borders/edges No exudate or clear, serous exudate which can cause the skin to glisten No slough or eschar Burning pain, itching
Risk Factors - Intrinsic
Very young (neonate) or very old (> 75 years of age) Immobility Dependence in ADLs Compromised nutrition or hydration status Cognitive impairment and/or decreased sensation Visual impairment History of skin tears Existing skin conditions: ecchymosis, senile purpura, hematoma, frail fragile skin Multiple chronic conditions
Risk Factors for Ulceration
Visual impairment or retinopathy Peripheral arterial disease Neuropathy Foot deformity Limited ankle range of motion High plantar foot pressures Minor trauma Previous ulceration or amputation.
