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Wound Measuring And Staging Inservice


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Pressure Ulcer Inservice for Nurses

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Wound Measuring And Staging Inservice

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