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Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
Wound Measuring And Staging Inservice
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Wound Measuring And Staging Inservice

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Pressure Ulcer Inservice for Nurses

Pressure Ulcer Inservice for Nurses

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  • 1. St. John’s Hyperbaric and Wound Treatment Center Lisa Hezel, RN WCC
  • 2. Measuring and Staging Wounds
  • 3. Measuring and Staging Wounds
    • Chronic refractory osteomyelitis of right heel
    • Plantar surface of the foot
    • Caused by pressure from a poorly fitting shoe, patient is diabetic
    • How do we measure this wound?
    • How do we stage this wound?
  • 4. Measuring and Staging Wounds
    • Official Statement concerning this in-service!!
    • This staging system was developed by the NPUAP(National Pressure Ulcer Advisory Panel) and classifies only pressure ulcers based on anatomical depth of soft tissue damage.
    • Another system for diabetic foot ulcers only is called the Wagner system and is usually utilized by podiatrists. We will not cover that today.
  • 5. Measuring and Staging Wounds
    • STAGE 1- An observable pressure related alteration of intact skin whose indicators may include one or more of the following:
      • skin temperature (warmth or coolness)
      • tissue consistency (firm or boggy)
      • sensation (pain/itching)
      • appears as defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, this ulcer may appear with persistent red, blue or purple hues.
  • 6. Measuring and Staging Wounds
    • Examples of Stage 1 Pressure Ulcers
  • 7. Measuring and Staging Wounds
    • Stage 2 -Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
      • Pink
      • Partial
      • Painful
      • NEVER has slough,eschar or undermining
  • 8. Measuring and Staging Wounds
    • Examples of Stage 2 Pressure Ulcers
  • 9. Measuring and Staging Wounds
    • Stage 3- Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to but not through , underlying fascia.
      • The ulcer presents clinically as deep crater with or without undermining of adjacent tissue.
  • 10. Measuring and Staging Wounds
    • Examples of Stage 3 pressure wounds.
  • 11. Measuring and Staging Wounds
    • Stage IV—Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (ie. Tendon, joint capsule)
      • Undermining and sinus tracts may be associated w/ stage IV ulcers
      • Can differentiate from stage III ulcers because it will go PAST the Fascia
  • 12. Measuring and Staging Wounds
    • Example of a stage IV wound
      • Past the skin, subcutaneous level and goes to the calcaneous bone
  • 13. Measuring and Staging Wounds
    • Unstageable Pressure Ulcer—A pressure ulcer cannot be accurately staged until the deepest viable tissue layer is visible; this means that wounds covered w/ eschar &/or slough should be documented as unstageable.
      • EXCEPTION : In Longterm Care, the MDS form states that if a wound is covered w/ enough eschar/necrotic tissue which prevents adequate staging, then the code for that form will be a Stage IV pressure ulcer.
  • 14. Measuring and Staging Wounds
    • Examples of Unstageable Pressure Ulcers.
  • 15. Measuring and Staging Wounds
    • Deep Tissue Injury—describes a variation of pressure ulcers that appear initially as bruised or dark tissue.
      • The location is the muscle bed or subcutaneous fat.
      • The skin is usually intact at time of initial assessment.
      • No Recognized diagnostic tools can identify pressure related deep tissue injury under intact skin, therefore you must rely on visual inspection and palpation.
      • The area may be painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
  • 16. Measuring and Staging Wounds
    • Proposed Etiology of DTI—
      • Pressure to the skin and soft tissue and ischemia
      • Muscle injury associated with a decrease in nutrient supply
      • Injury or damage to the fascia from shearing injury or torsion of the perforating vessels
  • 17. Measuring and Staging Wounds
    • Deep Tissue Injury--The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
    • DTI over a heel may look like a bruise or blood blister
  • 18. Measuring and Staging Wounds
    • Classification Of Wounds
      • Non pressure related wounds are classified as either Partial or Full thickness.
        • Venous Stasis Ulcers
        • Skin Tears
        • Burns
  • 19. Measuring and Staging Wounds
    • Partial Thickness—destruction of the epidermis and dermis—You will never see slough in a partial thickness wound!
                                                                                                                                         
  • 20. Measuring and Staging Wounds
    • Full Thickness—Destruction of epidermis and dermis, subcutaneous and or deeper.
    • http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962006000600002&tlng=en&lng=en&nrm=iso
  • 21. Measuring and Staging Wounds
    • Burns
      • Superficial
      • Superficial partial thickness
      • Deep Partial Thickness
      • Full Thickness
  • 22. Measuring and Staging Wounds
    • Linear Style for Measuring wounds
      • Length X Width X Depth
      • Wound edge to wound edge in a straight line
      • Consider the wound as a face of a clock—12 points to the patient’s head and 6 to the patient’s feet.
  • 23. Measuring and Staging Wounds
    • Measuring on the foot using the clock system—Can be tricky! Just pretend your patient is a ballerina with her toes pointed and the heel will be 12:00 and the toes will be 6:00.
  • 24. Measuring and Staging Wounds
    • To obtain measurements:
      • Measure the longest from 12-6 on the clock and 3-9 on the clock.
      • This keeps the measurements consistent from week to week.
      • When in doubt: draw a picture of what you measured to make it easier for the next nurse!
  • 25. Measuring and Staging Wounds
    • Depth—Distance from visible surface to the deepest area.
      • Cotton tip applicator to the deepest portion of the wound.
      • Grasp the applicator w/ finger and thumb at the point corresponding to the wounds margin.
      • Withdraw from wound while maintaining position of finger and thumb on the applicator.
      • Measure from tip of applicator to position against a centimeter ruler.
  • 26. Measuring and Staging Wounds
    • Tunneling and Undermining—measure and document depth and direction.
      • Use cotton tip applicator and gently probe around wound edges in clockwise direction.
      • Once tunneling/undermining have been identified, insert applicator into that area.
      • Grasp the applicator where it meets the wound edge w/ thumb and forefinger.
      • Withdraw the applicator while maintaining the position of the thumb and forefinger.
      • Measure from the tip of the applicator to the position.
      • Document based on a time on the clock ie. Tunneling at 1 o’clock measures 2 cm.

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