Pressure Ulcer

what stage is bruising

*—Bruising indicates deep-tissue injury.

What Is the Best Way to Cleanse and Dress a Pressure Ulcer? A; Pressure ulcers should be cleansed with saline or tap water. B. Wet-to-dry dressings, C. povidone-iodine (Betadine) solution, and D. Dakin's solution should be avoided E. H2O2 F. hydrocolloid, foam, or other nonadherent dressing G. G. saline and gauze (wet to moist)

ANSWER IS A AND F AND G Pressure ulcers should be cleansed with saline or tap water. They should be debrided of slough and necrotic tissue. A hydrocolloid, foam, or other nonadherent dressing that promotes a moist wound environment should be used. Wet-to-dry dressings, povidone-iodine (Betadine) solution, and Dakin's solution should be avoided. Pain associated with cleansing or dressing pressure ulcers should be treated appropriately.

stage 2

Stage 2 pressure injuries: involve partial-thickness skin loss with exposed dermis. They are shallow and have a red-pink wound bed. An intact blister is also considered a stage 2 injury. There should be no slough (dead tissue that is often a yellow-gray color and tightly adhered) or bruising in a stage 2 ulcer Partial-thickness loss of skin or tissue presenting as a shallow open ulcer with a red-pink wound bed, without slough; may present as an intact or open/ruptured serum-filled or serosanguineous blister; presents as a shiny or dry, shallow ulcer without slough or bruising*; this category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation

https://www.aafp.org/afp/2015/1115/p888.html

common Qs about pressure ulcer

The most commonly used staging system for pressure ulcers is the National Pressure Ulcer Advisory Panel staging system

4 stages

A 75 yr old bed bound end stage of Parkinson's disease has a home health nurse visit to take care several pressure ulcers. The home visit nurse called you to report a prolong dark eschar on the R heel area. She reported that the heel eschar looks dry, adherent, intact without erythema or fluctuance. it has been there for couple of months. She wants to get your instruction how to manage this eschar. A: wet dry wound pad B: debridement C. call surgical consel D. leave it alone E: apply Vasolin F: H2O2

D. stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as a natural (biological) cover and should not be removed

stage 3 pressure injury:

Full-thickness skin 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; depth of ulcer varies by anatomic location; bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and ulcers can be shallow; in contrast, areas of significant adiposity can develop extremely deep ulcers; bone/tendon is not visible or directly palpable

Unstageable pressure injury: obscured full-thickness skin and tissue loss

Full-thickness tissue loss in which actual depth of ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed; until enough slough or eschar is removed to expose the base of the wound, the true depth cannot be determined, but it will be stage 3 or 4; stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as a natural (biological) cover and should not be removed

4

Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling; depth of ulcer varies by anatomic location; bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and ulcers can be shallow; ulcers can extend into muscle or supporting structures (e.g., fascia, tendon, joint capsule), making osteomyelitis or osteitis likely to occur; exposed bone/muscle is visible or directly palpable

stage 1

In a stage 1 injury, the skin is intact with non-blanchable redness, or differing color from surrounding skin in darkly pigmented skin. The area may be warm, cool, soft, firm, or painful compared with other areas. Patients with stage 1 injuries are at risk of developing additional pressure injuries

Does Nutritional Supplementation Improve Prognosis?

Protein supplementation may improve outcomes in the treatment of pressure ulcers.4,22 There is no evidence to support the use of vitamin C or zinc to treat pressure ulcers in patients who are not deficient of these nutrients

Deep-tissue pressure injury: persistent non-blanchable deep red, maroon or purple discoloration

Purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure or shear; area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared with adjacent tissue; deep-tissue injury may be difficult to detect in patients with dark skin tones; evolution may include a thin blister over a dark wound bed; wound may further evolve and become covered by thin eschar; evolution may be rapid, exposing additional layers of tissue even with optimal treatment

When Should Osteomyelitis or Other Infectious Complications Be Considered?

The decision to treat a pressure ulcer for infection should be a clinical one. Ideally, evidence of infection is confirmed by tissue or bone biopsy. Superficial cultures usually are not useful other than to rule out methicillin-resistant Staphylococcus aureus (MRSA) colonization. Systemic rather than topical antibiotics should be used to treat an infected pressure ulcer.

What stage is eschar or yellow slough?

at least stage 3 or 4 since the depth is not know until clearing the slough or eschar.