THE IMPACT OF PRESSURE ULCERS

Today’s term for these lesions is pressure ulcer, because this describes more accurately what has happened to the skin and underlying structures, and why. In the past, they would have been called bedsores, decubitus ulcers, decubiti, or pressure sores.

Recent figures indicate that 2.5 million patients are treated annually for pressure ulcers in acute care facilities in the United States (IHI, 2007). The impact of pressure ulcers is staggering.

First and foremost, these wounds are very painful, thus causing patients a great deal of suffering.

The anatomical location of the ulcer may result in a loss of dignity.

Quality of life is affected as the patient must alter activities to help heal the wound or may face long-term hospitalization.

A non-healing ulcer is at high risk for infection, which can be life-threatening.

Ulcer treatments may require surgical procedures such as debridement, colostomies, and amputations, which the patient would otherwise not have to face.

An ulcer that heals forms scar tissue, which lacks the strength of the original tissue and is more easily ulcerated again and again.

Most importantly, the presence of a pressure ulcer increases the risk of death. Nearly 60,000 hospital patients in the United States are estimated to die each year from complications due to hospital-acquired pressure ulcers (IHI, 2007).

Healthcare costs increase dramatically due to pressure ulcers. An estimated $11 billion are spent each year to treat pressure ulcers. The inpatient length of stay is 3–5 times longer for those with a pressure ulcer. Patients with either a primary or secondary diagnosis of pressure ulcer are discharged to long-term care at 3 times the rate of other diagnoses (WOCN, 2010).

The nurse’s workload increases as now additional time and care must be provided to the patient to manage and treat the ulcer—more dressing changes, more medications, more documentation.

Litigation may be brought against a hospital and its staff for neglect, malpractice, and elder abuse if a patient develops a pressure ulcer while in the hospital. Awards can be in the millions of dollars. And the bad publicity that follows will hurt the hospital’s reputation and bottom line.

Pressure ulcers are now reportable to state and federal agencies. The information is placed in databases that can be accessed by the public. These governmental agencies may levy fines against the hospital for avoidable pressure ulcers. The Center for Medicare and Medicaid (CMS) no longer pays a hospital for the additional care needed for a patient who develops a hospital-acquired pressure ulcer (HAPU), but the hospital must provide the care nonetheless.

In the long-term care setting, the Joint Commission has made the prevention of healthcare-associated pressure ulcers a “2011 National Patient Safety Goal” (Joint Commission, 2011).

Thus, the prevention, assessment, and treatment of pressure ulcers are of major importance to nurses and other caregivers and to the healthcare facilities at which we practice.

RISK ASSESSMENT

The purpose of assessing the risk for developing pressure ulcers is so that interventions can be implemented to prevent the formation of these ulcers.

Risk Assessment Schedules

Risk assessment should be performed when a patient is admitted to a healthcare setting. It should be repeated on a regularly scheduled basis and/or when there is a significant change in the patient’s condition, such as surgery or a decline in their health status (EPUAP/NPUAP, 2009).

A schedule for reassessing risk should be based on the acuity of the patient and knowledge on when pressure ulcers are most likely to occur in a clinical setting. Every patient must be assessed and reassessed, not just the ones who seem most likely to develop ulcers. Recommendations are based on the healthcare setting are included in the box below. (A particular facility or setting may have different regulations.)

In acute care, pressure ulcers usually develop within the first 2 weeks of hospitalization. Elderly patients can develop pressure ulcers within the first week of hospitalization. In ICU, ulcers can develop within 72 hours of admission.

In both home health and long-term care settings, most pressure ulcers develop within the first 4 weeks. In the hospice setting, most pressure ulcers occur within two weeks of death (WOCN, 2010).

ASSESSMENT SCHEDULES BY HEALTHCARE SETTING

Acute Care: The initial assessment is done on admission and reassessment at least every 24–48 hours or whenever the patient’s condition changes. Most ICUs reassess each shift, while a med-surg unit may reassess daily.

Home Health: The initial assessment is done on admission, and reassessment is done at resumption of care, recertification, transfer or discharge, or whenever the patient’s condition changes. Some agencies reassess with each nursing visit.

Long-term Care: In skilled facilities the initial assessment is done on admission and weekly thereafter. In nursing homes with long-term patients, the assessment is done on admission, weekly for the first month, then monthly thereafter, or whenever the patient’s condition changes.

Source: WOCN, 2010.

Determining Risk Levels

Several risk assessment tools or scales are available to help predict the risk of a pressure ulcer. They consist of several categories, with scores that when added together determine the total risk score. The Braden and Norton Scales are the most widely used for predicting pressure ulcer risk in a variety of healthcare settings. These tools are used to help the clinician determine risk so that interventions can be started promptly.

BRADEN SCALE

The Braden Scale consists of six categories. Sensory perception, moisture, activity, mobility, and nutrition are rated 1–4. Friction/shear is rated 1–3. The total score can thus range from 6–23. The higher the score, the lower the risk.

Mild Risk: 15–18 Moderate Risk: 13–14

High Risk: 10–12

Very High Risk: 9 or below

It is recommended that if other risk factors are present—such as age, fever, poor protein intact, or diastolic blood pressure less than 60 mm Hg—the risk level should be advanced to the next level.

NORTON SCALE

The Norton Scale consists of five categories—physical condition, mental condition, activity, mobility, and incontinence—that are rated 1– 4, with a possible total score ranging from 5 to 20.

Mild Risk: 14 Moderate Risk: 13

High Risk: 12

It is important that when the clinician uses these scales, the scale must not be altered in any way, meaning there cannot be shortcuts or changes to the definitions. Any changes would alter the accuracy and usefulness of the scale in predicting the risk of developing pressure ulcers.

Risk Factors

Certain groups of patients have a higher risk for developing pressure ulcers. These include geriatrics, spinal cord injury, and critical care patients. Patients over 65 years of age are at high risk, and those over 75 are at even greater risk. Those who have fractured a hip or live in long-term care facilities are at an increased risk for heel pressure ulcers. Spinal cord–injured patients are at high risk for development and recurrence of pressure ulcers. Spasticity increases the risk of skin breakdown, as does the extent of the paralysis, a younger age at onset, difficulty in practicing good skin care, and a delay in seeking treatment or implementing preventive measures. As noted earlier, ICU patients can develop pressure ulcers within 72 hours.

AGING SKIN AND PRESSURE ULCERS

Obvious changes in both skin structure and function occur with aging. These changes contribute to the occurrence of skin and wound problems.

Flattening of the epidermal-dermal junction decreases the overall strength of the skin, which increases the risk for skin tears and blistering.

Decrease in the melanocytes and Langerhans cells increases the risk for allergic reactions and sensitivity to sunlight.

Decreased blood flow decreases skin temperature.

Decreased production of oil and sweat contributes to dryness and flaking.

Decreased subcutaneous tissue, especially fat, decreases the body’s natural insulation and padding.

Decline in the reproduction of the outermost layer of the epidermis may lead to the skin’s inability to absorb topical medications.

These changes in skin structure and function, together with the risks that occur with a change in overall health and functional ability, put the aged patient at very high risk for the formation of a pressure ulcer.

There are other risk factors that may increase the chance of developing a pressure ulcer. More than 100 of them have been reported (WOCN, 2010). These include:

General medical conditions, such as diabetes, stroke, multiple sclerosis, cognitive impairment, cardiopulmonary disease, cancer, hemodynamic instability, peripheral vascular disease, malnutrition, and dehydration

Smoking

History of a previous pressure ulcer

Increased length of stay in a facility

Undergoing a long surgery

Significant weight loss

Emergency room stays

Prolonged time on a stretcher

Medications, such as sedatives and analgesics

Refusal of care

Edema

Obesity

Not turning the patient

For patients in the ICU: moisture problems, receiving norepinephrine, anemia, fecal incontinence, and increased length of stay

What to Assess

Prevention of pressure ulcers must begin with frequent and routine assessment of the patient’s skin and of the risk factors that, if left unmanaged, will contribute to the development of an ulcer.

SKIN

A head-to-toe inspection of the skin should be done on admission and at least daily (or per facility regulation). It should focus on high-risk areas such as bony prominences. The specific areas to assess are the occiput, sacrum, heels, and trochanters if the patient is bed-bound and the ischial tuberosities and coccyx if the patient is chair-bound.

The Center for Medicare and Medicaid (CMS) recommends five parameters of skin assessment: skin temperature, skin color, skin texture/turgor, skin integrity, and moisture status (WOCN, 2010).

Blanchable erythema is a reddened area that temporarily turns white or pale when pressure is applied with a fingertip. This is an early indication of pressure. Nonblanchable erythema is redness that persists when fingertip pressure is applied. It means that tissue damage has already occurred.

It can be difficult to identify skin problems in patients with dark skin. Redness may not be easy to see. The clinician needs to compare the at-risk area (such as the coccyx or hip) with skin next to it and look for color differences or changes in temperature or pain.

Special garments or devices, such as shoes, heel and elbow protectors, splints, and others, must be removed and the skin inspected at least daily. Pressure ulcers have been caused by such devices.

IMMOBILITY

Immobility is the most significant risk factor for pressure ulcer development. Patients who have some degree of immobility need more frequent monitoring to prevent pressure ulcers and include those who are:

Nonambulatory Confined to bed, chairs, wheelchairs, recliners, or couches for long periods of time

Have paralysis and/or contractures

Wear orthopedic devices that limit function and range of motion

Require assistance to ambulate, reposition themselves, or get out of bed and chairs

FRICTION AND SHEARING

Friction is the mechanical force of two surfaces moving across each other; damage includes blisters or abrasions. Patients who cannot lift themselves during repositioning and transferring are at high risk for friction injuries. Shearing is the mechanical force that is parallel to the skin and damages deep tissues like muscle. Tissues attached to the bone are pulled in one direction while surface tissues remain in place. Shearing most commonly occurs when the head of the bed is elevated and the patient slides downward.

INCONTINENCE

Moisture from incontinence can contribute to pressure ulcer development by macerating the skin and increasing friction injuries. Fecal incontinence is even a greater risk for pressure ulcer development than urinary incontinence because the stool contains bacteria and enzymes that are caustic to the skin. When both urinary and fecal incontinence occur, the fecal enzymes convert the urea in the urine to ammonia, which raises the skin’s pH. When the skin pH is elevated (alkaline), the skin is more susceptible to damage. Pressure ulcers are 4 times more likely in incontinent patients than those who are continent (WOCN, 2010).

NUTRITIONAL STATUS

Although individual nutrients and their specific role in preventing pressure ulcers have not been determined, malnutrition is associated with overall morbidity and mortality. A nutritional assessment should be done on admission and whenever there is a change in the patient’s condition that would increase the risk of malnutrition.

HISTORY

It is important to assess the history of a pressure ulcer or presence of a current ulcer. Assessment and regular monitoring of the pressure ulcer must be done on admission and at least weekly for signs of skin or wound deterioration.

PRESSURE ULCER PREVENTION

As the saying goes, “an ounce of prevention is worth a pound of cure.” It is more cost efficient to prevent a pressure ulcer than to cure one. Interventions that will help the clinician prevent pressure ulcers do so from both an inside and outside approach. From the outside, the clinician can minimize pressure through regular repositioning, the use of a support surface, and managing incontinence to prevent skin damage from moisture. The inside approach includes the management of nutrition and hydration to support the body in preventing damage and healing any damage that has occurred.

Regular Repositioning

As previously stated, immobility is the most significant risk for the development of pressure ulcers. High pressures over bony prominences for a short time and low pressures over bony prominences for a long time are equally damaging (EPUAP/NPUAP, 2009). In order to decrease the risk, it is important to reduce the time and amount of pressure the patient is exposed to.

All patients must have their positions changed on a regular schedule. How often this is done is determined by their own activity/mobility level, general medical condition, the overall treatment plan, the condition of the skin, and the support surface being used.

BED-BOUND PATIENTS

For bed-bound patients, the standard “turn every 2 hours” may be more than adequate for some and not at all adequate for others. A patient needs to be repositioned more often on a standard mattress than on a pressure-redistributing mattress. If the medical condition is so severe that repositioning the patient regularly is not possible, then a support surface designed to decrease pressure must be used.

When we think of turning the patient, we often think that the patient must be completely over on a side. This can be difficult for the clinician/caregiver to do, is uncomfortable for the patient, can result in cardio-pulmonary compromise, and actually increases pressure on the side of the body.

Frequent small position changes, rather than completely turning the patient, is faster, easier, and safer for all. Any change in position is beneficial. The patient need only be tilted to the side, no more than 30 degrees, with pillows or wedges to help support and reduce the pressure over bony prominences. A small pillow behind the shoulder or the hip alters position without having to move the entire body. Bending the knee alters the pressure on the sacrum and hip. A small pillow behind the heel will elevate the heel off the surface and prevent pressure.

When a patient is moved, it must be done in a way as to prevent friction and shearing, as these forces will cause skin injury as readily as pressure. Always use a lift sheet or lift equipment to reposition the patient. The patient must be lifted, not dragged, while repositioning, which also means more than one person may be needed to move the patient. Pulling or dragging the patient will cause skin damage due to friction.

Maintain the head of the bed at or below 30 degrees (or the lowest degree of elevation allowed based on the medical condition) to prevent the body from sliding down and causing a shear-related injury (WOCN, 2010). Lower the head of the bed 1 hour after meals or intermittent tube feedings. If this is not possible, the sacral region will need to be checked even more frequently for possible injury.

Have the patient assist in moving by using overhead trapeze bars. Even if the patient can only hold onto the bar, some of the weight will be reduced, making it easier and safer to move. After the patient has been repositioned, be sure that he or she is not lying on a medical device, such as tubes or drains, and make sure the linens are smoothed.

CHAIR-BOUND PATIENTS

A chair-bound patient must be repositioned as well. When a patient is seated, the weight of the body causes the greatest amount of pressure to occur over the ischial tuberosities. Since this area of the body is relatively small, the amount of pressure will be high; without pressure relief, a pressure ulcer will occur quickly. If the patient cannot sit upright but slouches in the chair, then the sacral area is at risk as well.

Recommendations for the chair-bound patient include:

Stand the patient and reseat them in the chair. Elevate the legs or place the feet on a stool if the feet do not reach the floor. This will

prevent sliding forward out of the chair.

Elevate the feet and recline the chair by 30 degrees to reduce pressure.

If the patient can change his/her own position, encourage pressure relief every 15 minutes. This includes chair pushups, leaning forward, leaning side to side, or tilting backwards. Leaning forward is the most effective and might be easier than chair push-ups.

Acutely ill patients at risk for pressure ulcers should not sit for longer than 2 hours at a time and not return to sitting for at least an hour.

Patients with existing pressure ulcers on the ischial areas should limit time sitting up in the chair to 3 times a day for 60 minutes or less and they must use a cushion (gel or air cushions are best) that redistributes pressure (WOCN, 2010).

Physical and occupational therapists are of great importance in assessing and managing the immobile patient’s activities and instructing staff, patients, and families in proper techniques to avoid injury and prevent ulcers.

Support Surfaces

There is no mattress or cushion that will eliminate pressure and relieve the clinician or caregiver from having to turn the patient. Patients must still be turned, no matter what surface is used. Support surfaces on beds and chairs are used, however, to more evenly distribute body-weight pressure and to help reduce pressure to any one area of the body.

CHOOSING A SURFACE

Determining the appropriate support surface is based on the patient’s condition and the healthcare setting. Overall, if the patient is able to be turned and has at least two intact turning surfaces, meaning the skin is intact on two sides of the body, then a mattress overlay or an alternating pressure pad can be used over a regular mattress. If the patient has breakdown on more than one side of the body, then a low–air loss mattress replacement should be used.

Cost and product availability must be considered in choosing a surface. The healthcare setting will also determine the product used. For instance, in the home setting the weight of the bed, the

structure of the home, the width of the doors, and the availability of uninterrupted electrical power will have a major impact on the support surface available for use.

In general, an ordinary, standard hospital mattress should not be used with at-risk patients. Be sure to contact the medical equipment department to determine what is available for pressure reduction (WOCN, 2010).

Do not use rings, foam cutouts, or donuts under the patient, as these concentrate pressure on surrounding tissue, causing swelling and decreasing circulation.

TYPES OF SUPPORT SURFACES

Replacement mattresses: Mattresses with pressure-reducing features placed on an existing bed frame in place of at the standard mattress

Overlays: A support surface placed on top of a standard mattress; made of foam, water, gel, air, or a combination

Foam: A thick slab of foam with a textured surface placed on top of a standard mattress to reduce pressure by surrounding the body; should be at least 3–4 inches thick to be effective at reducing pressure (2 inches is for comfort only)

Water: A vinyl mattress or overlay with sections filled with water to distribute pressure more evenly and create a flotation effect

Gel: Made of a thick fluid that conforms to the contours of the body

Air: A vinyl mattress or overlay inflated with a blower to reduce pressure; powered or dynamic mattresses have a pump that inflates the mattress sections in an alternating cycle

Low–air loss: A mattress or overlay with controlled air-flow sections

Air-fluidized: Uses a high rate of blown air to fluidize fine particulate material (such as silicone beads) to “float” the patient on the surface

ENSURING EFFECTIVENESS

With the use of any support surface, the number of linens and other items used under the patient must be kept at a minimum or the pressure-reducing ability of the surface will be altered significantly. Staff, patients, and family members must be instructed to use no more than two items between the patient and the surface, e.g., one pull sheet and one incontinence pad or product.

The support surface must also be checked for adequate support to prevent “bottoming out.” To do this, place a hand (palm up) under the mattress or cushion below the area that is at risk (for example, the sacrum or hip) and push up against the mattress. If less than 1 inch of support material is felt, or if the body can be felt through the mattress, there is not enough support and the support surface is either malfunctioning or not adequate for the patient and will need to be replaced.

Regardless of the surface used, the patient’s heels must be floated off the bed using either a pillow or a heel-lift device. The recommended position for the pillow is lengthwise under the calf with the heel suspended in the air. The patient must be turned at regular intervals to promote pulmonary, renal, and vascular function along with protecting skin integrity. Padded devices such as synthetic sheepskin, bunny boots, or rigid splints protect the heels from friction and shearing but do not relieve pressure. Devices such as an IV bag, rolled towel, or sheet do not redistribute pressure and can actually increase pressure (WOCN, 2010).

Managing Incontinence

Skin moisture from incontinence is a risk factor for pressure ulcer development. Water saturates the skin, which increases the risk that friction and shearing will result in erosion of the skin. The ammonia in urine raises the skin’s pH, which promotes growth of pathogenic bacteria, disrupts the protective acid mantle, and activates fecal enzymes. Fecal enzymes damage the skin, allowing the gastrointestinal bacteria to cause infections. These result in a condition called incontinence associated dermatitis (IAD). In and of itself, IAD is not a pressure ulcer. But if unrelieved pressure is added to IAD, the odds are 5 times higher that a pressure ulcer will develop. Proper cleansing and protection of the skin are the basis of prevention of IAD (Gray, et al, 2007).

Cleanse the skin gently at each time of soiling with a pH-balanced cleanser. Perineal skin cleansers are more effective for prevention and treatment of IAD than traditional soap and water. This is because bar soap is alkaline and very drying to the skin, which disrupts its protective abilities. Vigorous cleaning as well as the use of rough washcloths can also lead to skin erosion. Soft, disposable cloths are easier on the skin. Cleaning products with fragrance or alcohol should be avoided, as these are irritants. Some facilities use no-rinse foams, and these are also a good option.

An incontinence skin barrier product should be used to protect the skin after cleansing. Products such as creams, ointments, pastes, or those that form a film on the skin are all useful. Protective products with dimethicone, petroleum, or zinc oxide are recommended for patients with fecal incontinence or both urinary and fecal incontinence to protect against IAD. Several manufacturers offer products that both clean and protect, which can save time and make perineal care easier for the caregiver and more likely that it will be done each time.

Select underpads or incontinence briefs that are absorbent to wick moisture away from the skin instead of those that trap the moisture against the skin. However, all briefs increase moisture at the perineal region because they are occlusive and do not “breathe.” This creates warmth near the skin that, when combined with moisture, ammonia, and enzymes, increases skin breakdown. There is an increased risk with the use of briefs because they may not be changed as often as they should be due to the difficulty in seeing when a patient has voided. Briefs are not recommended for fecal incontinence because they can trap stool against the skin.

Many hospitals have moved away from using briefs except when a patient is ambulating or going off of the ward. Instead, they use underpads that wick and hold fluid away from the skin, do not trap heat and moisture next to the body, and can readily be seen when they need to be changed.

A toileting program can also decrease incontinence and thus IAD. For those patients with significant fecal output, a pouching system or fecal containment device may be necessary to protect the skin from the effluent. In situations where the severity of urinary incontinence has contributed to or may contaminate an existing pressure ulcer, an indwelling catheter may be indicated (WOCN, 2010).

Nutrition Management

Malnutrition is associated with overall morbidity and mortality. Thus, assessing the patient’s nutritional status must be part of the total assessment. The assessment should be performed upon admission to a new healthcare setting and whenever there is a change in the patient’s condition which puts them at risk for under-nutrition.

NUTRITION ASSESSMENT PARAMETERS

Current weight and usual weight History of unintentional weight loss or gain (greater than 5% change in 30 days or greater

than 10% change in 180 days)

Body mass index (BMI)

Food intake

Dental health

Ability to chew, swallow, and feed oneself

Medical and/or surgical history that influence intake or absorption of nutrients

Drug/food interactions

Psychosocial factors that can affect food intake:

Ability to obtain and pay for food

Facilities for cooking and eating

Food preferences

Cultural and lifestyle influences on food selection

Advanced age

The patient should be monitored for signs of dehydration, such as decreased skin turgor and/or urine output or elevated serum sodium. Serum protein tests, such as for albumin and pre-albumin, may be affected by inflammation, renal function, and hydration and so may not correspond with overall nutritional status. Thus, laboratory tests should be considered as only one part of the nutritional assessment.

While there is evidence that adequate nutritional support for stage III and IV pressure ulcers is a strong predictor of pressure ulcer healing and that support with high protein can significantly reduce the risk of pressure ulcers, there is no evidence to support that specific supplements promote the healing of ulcers. Studies that show support are small and more research needs to be done (WOCN, 2010).

Any patient with nutritional and pressure ulcer risks, suspected or identified nutritional deficiencies, or a need for nutritional supplementation to prevent undernutrition should be referred to a registered dietician. Any patient with a pressure ulcer should be referred to a dietician as well (WOCN, 2010).

DEFINING AND STAGING PRESSURE ULCERS

Over the years the definition of a pressure ulcer has been refined, most recently in 2009. A pressure ulcer is now defined as “a 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” (EPUAP/NPUAP, 2009).

Common terms for pressure ulcer include bedsore, decubitus ulcer, pressure sore, and pressure ulcer. The terms bedsore and decubitus ulcer originated from the notion that to develop ulcers a person needed to be bedridden, which we now know is not the case. Ulcers can develop when a patient constantly maintains any position; consequently the term pressure ulcer most accurately describes an ulcer from pressure.

The compression of soft tissue interferes with the tissue blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure ulcers usually occur over bony prominences such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Other factors previously mentioned also contribute to the tissue breakdown. Pressure ulcers can develop within 24 hours of the initial pressure but take as long as 5 days to present themselves.

Stages

Pressure ulcers are staged to classify the degree of tissue damage that is present. The staging system was originally created in 1975 as a means to describe the amount of anatomical tissue loss in a pressure ulcer. The use of stages in pressure ulcer assessment is a way to classify the amount and type of tissue destroyed based on anatomic depth. Having and using a common classification system allows all clinicians a way of communicating accurately what is wrong. It is only used to describe pressure ulcers, not other wounds.

The most recent definition of the stages from the National Pressure Ulcer Advisory Panel (EPUAP/NPUAP, 2009) is as follows:

STAGE I

A Stage I pressure ulcer is defined as intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its

color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

A blanchable redness means that when the red area is compressed by the finger, the area turns white or pale and the redness returns when the pressure is released. Nonblanchable redness means the area under the finger remains red as it is compressed. Nonblanchable redness indicates that tissue damage has already occurred. (See figure.)

Stage I Pressure Ulcer(Sources: [illustration] © National Pressure Ulcer Advisory Panel, used with permission; [photo] © Wound, Ostomy and Continence Nurses Society (WOCN), used with permission.

STAGE II

A Stage II pressure ulcer refers to partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister or as a shiny or dry shallow ulcer without slough or bruising. (Bruising indicates deeper tissue injury.)

This stage should not be used to describe skin tears, tape burns, perineal dermatitis (incontinent associated dermatitis), maceration, or excoriation. "Partial thickness" means that the damage is confined to the epidermis and/or dermis but does not penetrate below the dermis. (See figure.)

Stage II Pressure Ulcer(Sources: [illustration] © National Pressure Ulcer Advisory Panel, used with permission; [photo] © Wound, Ostomy and Continence Nurses Society (WOCN), used with permission.)

STAGE III

A Stage III pressure ulcer includes full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling.

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 here will be shallow. In contrast, areas of significant fat deposits can develop extremely deep Stage III pressure ulcers.

Bone and/or tendon is not visible or directly palpable. "Full thickness" means the damage extends completely through the dermis to the subcutaneous layer. Slough is a soft, moist, avascular. (See figure.)

Stage III Pressure Ulcer(Sources: [illustration] © National Pressure Ulcer Advisory Panel, used with permission; [photo] © Wound, Ostomy and Continence Nurses Society, used with permission.)

STAGE IV

A Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. It often includes undermining and tunneling.

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 Stage IV ulcers here will be shallow.

Stage IV ulcers can extend into muscle and/or supporting structures, such as fascia, tendon, or joint capsule, making osteomyelitis possible. Exposed bone or tendon is visible or directly palpable. (See figure.)

Stage IV Pressure Ulcer(Sources: [illustration] © National Pressure Ulcer Advisory Panel, used with permission; [photo] © Association for the Advancement of Wound Care (AAWC), used with permission.)

The NPUAP has also described two additional categories of pressure ulcer: suspected deep tissue injury and unstageable (EPUAP/NPUAP, 2009).

SUSPECTED DEEP TISSUE INJURY

Deep tissue injury may be indicated by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage to the 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 may be difficult to detect in individuals with dark skin tones. Its 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. (See figure.)

Suspected Deep Tissue Injury(Sources: [illustration] © National Pressure Ulcer Advisory Panel, used with permission; [photos] © Association for the Advancement of Wound Care (AAWC), used with permission.)

UNSTAGEABLE

A pressure ulcer is considered unstageable in the case of full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown tissue) and/or eschar (tan, brown or black tissue) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; however it will be a Stage III or IV, as slough and/or eschar do not form in Stage I or II ulcers.

Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heels serves as the body’s natural or biological cover and should not be removed. (See figure.)

Unstageable Pressure Ulcer(Source: [illustration] © National Pressure Ulcer Advisory Panel, used with permission; [photo] © Association for the Advancement of Wound Care (AAWC), used with permission.)

Reverse Staging

The term reverse staging came about in the 1980s as a way of describing improvement in an ulcer. However, this term does not accurately describe what is physiologically occurring in the ulcer. Because staging is used only to describe the amount and type of tissue destroyed based on anatomic depth, it cannot be used to describe healing.

As a pressure ulcer heals it does decrease in depth, but the body does not replace the lost bone, muscle, subcutaneous fat, or dermis. Instead, the full-thickness ulcer is filled with granulation, or scar tissue, and then covered with new epithelium. Even a partial-thickness Stage II ulcer does not return to the nonblanchable redness of a Stage I ulcer. A Stage IV pressure ulcer that has closed should be classified as a closed Stage IV pressure ulcer and not as something like a “Stage O” pressure ulcer (which does not exist).

The progress of healing a pressure ulcer can only be documented using wound characteristics (decrease in length, width, depth, odor, drainage, pain, etc.) or using a validated pressure ulcer healing tool. If a pressure ulcer reopens in the same anatomical site, the ulcer resumes the previous staging diagnosis—once a Stage IV, always a Stage IV (EPUAP/NPUAP, 2009).

Current federal regulations require long-term care facilities to reverse stage at the present time for coding the Minimum Data Set (MDS). Until the MDS is revised, reverse staging must be

used for completion of the Resident Assessment Instrument. However, clinicians are urged to document healing using either descriptive characteristics of the wound or a validated tool such as the NPUAP Pressure Ulcer Scale for Healing (PUSH) tool to document pressure ulcer healing. This tool documents pressure ulcer healing that is consistent with the healing process (NPUAP, 2010).

PRESSURE ULCER TREATMENT

Treating a pressure ulcer involves all of the activities used in preventing a pressure ulcer: the proper pressure-reducing surface, repositioning the patient correctly and frequently, maintaining intact skin, and improving nutrition. While these interventions are being put into place, the treatment of the wound itself begins. There are basic wound care principles that can be used in deciding which treatments will be the best for the wound and for the patient. Frequent reassessment of the wound and its response to the treatment is required, as well as eliminating or reducing the factors that inhibit wound healing.

Pressure Reduction

Of all the interventions that must be done to heal the ulcer, pressure reduction measures are the most important. Simply put, the wound will not heal unless the pressure is removed. Trying to heal a pressure ulcer without reducing the pressure is like trying to heal a stab wound with the knife still in it. You might get some improvement, but the wound will never heal because the primary cause has not been removed.

Repositioning and turning must be done regularly and frequently. Friction and shear must be prevented or a small ulcer will quickly turn into a large one with undermining and tunneling. The right support surface for the bed or the chair must be obtained and used. Management of incontinence will keep skin from getting worse. While outside impediments to healing are being managed, the inside impediments can be attended to through proper nutrition and by reducing other factors that affect healing. Dietician consult is always appropriate when treating a pressure ulcer.

Universal Principles of Wound Management

The object of treatment is to reproduce (to the best of one’s ability) the normal environment of the exposed tissue of the wound. The normal environment of all tissue and cells, with the exception of the epidermis, is warm, dark, moist, and protected. In order to heal any wound, including pressure ulcers, some basic principles need to be followed. These are:

Remove necrotic tissue Treat infection

Fill dead space

Maintain moist wound environment

Protect the wound from infection, trauma, and cold

Some of these principles will require medical intervention; others, good clinical care. By following these principles, caregivers will provide the wound with the environment it needs to heal.

REMOVING NECROTIC TISSUE

Removing necrotic tissue is the critical first step when healing the ulcer is the goal. By removing dead tissue, bacteria and the risk for infection are decreased as well as drainage and odor. Removing these materials may also contribute to the release of available growth factors in the wound, thus allowing the cells to multiply and heal the wound.

The removal of necrotic tissue is called debridement, of which there are several types. The most appropriate type of debridement will depend on the patient’s overall condition and goals of care. Factors to consider include the status of the ulcer; the type, quantity, and location of the necrotic tissue; the presence or absence of infection; pain tolerance; the care setting; and professional accessibility (EPUAP/NPUAP, 2009).

Surgical

Performed by a surgeon at the bedside or in the operating room, this is the quickest way to remove extensive necrotic tissue, undermining, and tunneling. However, the benefits of surgical debridement may outweigh the risks in the presence of advancing cellulitis, crepitus, fluctuance, and/or sepsis secondary to ulcer-related infection. Relative contraindications would include anticoagulant therapy, bleeding disorders, and immune incompetence. If the necrotic ulcer is on a limb, a thorough vascular assessment should be done prior to debridement to rule out arterial insufficiency. The NPUAP (EPUAP/NPUAP, 2009) recommends against debridement of stable, hard, dry eschar in ischemic limbs.

Sharp debridement, as opposed to surgical debridement, may be performed by specially trained, competent, qualified, and licensed healthcare professionals consistent with local legal and regulatory statutes. Sharp debridement removes only loose, easily identifiable necrotic tissue.

Autolytic

This method allows the body to break down necrotic tissue by using its own enzymes and defense mechanisms. This is done with the use of occlusive dressings such as hydrocolloids and films. These dressings help maintain a moist wound environment, reduce pain, and provide a barrier to infections. The dressing is left on for a few days, allowing the accumulation of fluids and enzymes at the site. The dressing is removed, the wound cleansed, and new dressing applied. This method takes time but is effective.

Chemical

This method involves the use of enzyme debriding agents. These breakdown necrotic tissue without affecting viable tissue. The enzyme product is applied daily to the necrotic tissue then covered by a dressing. Enzymes are by prescription only, and currently only one is available on the market.

Biosurgical

This method uses sterilized bottlefly maggots, which debride the wound by dissolving dead and infected tissue with their digestive enzymes (in other words, the maggots eat the dead tissue). The maggots also disinfect the wound by killing bacteria. This in turn stimulates the growth of healthy tissue. (For further information, see “Resources” at the end of the course.)

Mechanical

Mechanical debridement utilizes physical forces to remove necrotic tissue. The most common are the use of wet-to-dry dressings and high-pressure wound irrigation. (Use of whirlpools has fallen out of favor due to the difficulty in assuring the equipment is free of pathogens before its use on the next patient). High-pressure wound irrigation is done with commercially available devices such as pulsatile lavage units. A lower-pressure method to debride tissue is to use a 35-ml syringe with a 19-g needle, held a few inches from the wound. Care must be taken to minimize splashing and exposure to wound drainage, and infection control precautions should be followed.

The use of wet-to-dry dressings is no longer recommended. In this method, wet gauze is applied to the wound, and necrotic tissue is allowed to dry and then forcibly removed without re-wetting. The gauze will have stuck to the necrotic tissue, thus removing it when the gauze is removed. However, this method is nonselective in that healing tissue will also be removed, thus re-traumatizing the wound bed and causing significant pain.

TREATING INFECTION

Infection is not common is Stage I or II ulcers, so the focus for assessment of infection is on Stage III and IV ulcers. Pressure ulcers that are infected may exhibit subtle signs of infection—such as new or increased pain, delayed healing, poor or friable granulation tissue, discoloration of wound bed tissue, a change in odor, increased serous drainage, induration, or pocketing—before the classic signs of infection occur. There should be a high suspicion for the likelihood of infection in ulcers with necrotic tissue, those that have been present for a long time, those large in size, or those repeatedly contaminated, such as those near the anus.

Look for local infection in ulcers that have no signs of healing after 2 weeks of treatment. An acute infection may be present if there is redness extending from the ulcer edge, warmth, purulent drainage and odor, increase in size of the ulcer, and increase in pain. Systemic symptoms such as fever and malaise may develop. The elderly may develop confusion and anorexia. There must also be a high suspicion for the likelihood of infection in patients who have diabetes, malnutrition, hypoxia, autoimmune disease, or immunosuppression.

The gold standard method of determining wound infection is a by a culture of tissue obtained by biopsy. However, an acceptable alternative to a tissue culture is a swab culture obtained by the Levine technique (EPUAP/NPUAP, 2009).

LEVINE TECHNIQUE FOR WOUND CULTURE

Cleanse wound with sterile normal saline; blot dry with sterile gauze Culture the healthiest-looking tissue in the wound bed

Do not culture drainage, pus, necrotic tissue, or fibrous tissue

Rotate the end of a sterile alginate-tipped applicator over a 1 cm by 1 cm area for 5 seconds

Apply sufficient pressure with the swab to cause tissue fluid to be expressed

Send specimen to the lab

If the culture indicates infection, consider a two-week course of topical antibiotics. Consider systemic antibiotics if bacteremia, sepsis, advancing cellulitis, or osteomyelitis has occurred. Systemic antibiotics cannot reach necrotic tissue, so topical antibiotics are recommended in addition to systemic (EPUAP/NPUAP, 2009).

Silver- and honey-impregnated dressings are an option for ulcers infected with multiple organisms because these dressings offer broad antimicrobial coverage. Be sure the patient is not allergic to honey or to bees before using a honey dressing.

Topical antiseptics such as providone iodine, Dakin’s solution, or acetic acid that are properly diluted may be used for a limited time to control the bacterial burden, clean the ulcer, and reduce surrounding inflammation. Once the wound is clean, these products should be discontinued, as they can be damaging to healthy tissue. These products can also be used to control bacteria, drainage, and odor in wounds that are not expected to heal, such as in a terminally ill patient (EPUAP/NPAUP, 2009).

Cleansing the wound will also reduce the risk of infection. The ulcer and the surrounding skin must be cleansed at each dressing change. The cleansing method should provide enough pressure to removed debris yet not enough to cause trauma to the wound bed. Techniques for cleansing may include irrigation, gently swabbing the wound, or showering. Pressure ulcers that are healing may be cleansed with water. It can be tap water, distilled water, cooled boiled water, or saline. Avoid using cleansing products that are designed for use on intact skin, and avoid cleaners that are designed to remove fecal material; both of these can be toxic to a wound. When the wound has a lot of drainage or debris, a commercial wound cleanser may be used. Those that contain surfactants can help remove wound contaminants (WOCN, 2010).

FILLING DEAD SPACE AND MAINTAINING A MOIST ENVIRONMENT

Wound dressings are a central component of pressure ulcer care. The selection of the dressing for the ulcer is very important and based on many parameters, such as (WOCN, 2010):

Presence of infection or necrosis Size, depth, and presence of undermining or tunneling

Location

Drainage

Condition of the surrounding skin

Goals for healing

Individual or caregiver needs, such as pain reduction or odor control

Cost/reimbursement of the dressing

Availability

Ease of use

Maintaining a moist wound is a primary factor in dressing selection. If the ulcer is draining a large amount, then a dressing that will absorb but not dry out the wound is needed. If the ulcer has minimal drainage, then a dressing that replaces moisture and/or doesn’t allow the ulcer to dry out is needed.

The “dead” space inside the wound needs to be filled so that the dressing is in contact with the wound bed, including any tunneling or undermining. Do not stuff the wound with the dressing material; stuffing the wound puts pressure on the inside of the wound and will prevent exudate from draining out.

Dressings are changed based on the amount of drainage: a heavily draining wound will need to be changed often, while a minimally draining wound can be changed less than daily. There are many dressings available today to help maintain the correct environment to allow healing. Follow manufacturer recommendations for the use of the product (WOCN, 2010; EPUAP/NPUAP, 2009).

TYPES OF DRESSINGS

Hydrocolloid (e.g., Duoderm): A type of dressing containing gel-forming agents applied to a foam or a film, which form an absorbent, self-adhesive, waterproof occlusive wafer. These are used in Stage II ulcers in body areas where they will not roll or melt. They are also used for autolytic debridement. Expect the formation and/or collection of drainage under the wafer. This does not indicate infection but is a property of the product. Do not use on infected or heavily draining wounds or wounds in which the dressing needs to be changed more than 3 times per week. Remove carefully.

Transparent Film: Can be used to protect body areas at risk for friction injury. Can be used for autolytic debridement. May be used as a secondary dressing to hold in other dressings. Remove carefully.

Hydrogel: A water-based, non-adherent gel. Some hydrogel-based dressings have the ability to absorb excess drainage while providing moisture to dry necrotic tissue or slough. Generally, these dressings are used on shallow, minimally draining ulcers. They are covered with a secondary dressing.

Alginate: These are used in moderately and heavily draining ulcers. Cover with a secondary dressing.

Foams: Used in draining Stage II and shallow Stage III ulcers. They absorb drainage and protect the wound.

Silver-impregnated Dressings: An antimicrobial dressing used in ulcers that are infected or at high risk for infection. The silver is incorporated into foam, alginate, and other dressings. Consider discontinuing use when infection is controlled. Can turn tissues a dark color. Do not use in patients allergic to silver.

Honey-impregnated Dressings: Manuka honey is used for antimicrobial effects and can be effective on antibiotic-resistant bacteria while promoting healing. Use in Stage II and III ulcers. Do not use in patients allergic to bees or honey.

Cadexomer Iodine: An antimicrobial dressing that absorbs drainage and matter from the wound surface, and, as it becomes moist, iodine is released. Used in moderately to highly draining wounds. Do not use in patients with iodine sensitivity or thyroid disease. Difficult to use in large cavity wounds.

Gauze Dressings: A cotton or synthetic weave that is absorptive and permeable to water, water vapor, and oxygen. Gauze may be impregnated with petrolatum, antiseptics, or other agents. Gauze should not be used in clean ulcers, as they are labor-intensive to use, cause pain when removed if dry, and will dry out a wound. However, if no other dressing is available, the use of gauze that is kept continually moist is preferable to dry gauze. Moist gauze can be used to loosely fill a cavity wound and one with undermining and tunneling.

Negative Pressure Wound Therapy (NPWT): The use of NPWT has been associated with increased rates of healing in Stage III and IV pressure ulcers. Necrotic tissue must be debrided prior to using NPWT. Follow manufacturer’s guidelines for use.

Many of the advanced dressings do not need to be changed daily, which can reduce pain, time, and expense. Follow manufacturer directions.

PROTECTING THE WOUND FROM INFECTION, TRAUMA, AND COLD

Protecting the wound from infection, trauma, and cold can be done through the proper cleansing and dressing of the wound. As a wound heals and the drainage decreases, choose a dressing that does not have to be changed often. Every time a dressing is removed and the wound cleansed, the temperature of the wound bed drops to room temperature. The body then must expend energy to bring the wound bed back to body temperature so that cell repair and growth can continue. This can take several hours. Less frequent dressing changes aid the wound in healing by giving it time to do so. Protecting the wound from trauma includes the proper support surface, protection from incontinence, and the use of dressings that do not need to be changed frequently.

MONITORING RESPONSE

Stage I and II pressure ulcers should show evidence of healing within 1–2 weeks, and Stage III and IV ulcers should show evidence of healing within 2–4 weeks. This means that if after 2 weeks of treatment, no healing is detected, then the wound, the patient, and the plan of care need to be reevaluated.

With each dressing change, the ulcer is observed for anything that may indicate the need for a change in treatment—e.g., improvement or deterioration, more or less drainage, signs of infection, or other complications. Any signs of deterioration should be addressed immediately. The type of dressing may need to be changed based on this assessment.

Healing Assessment Tools

There are tools that have been developed that can be used to assess pressure ulcer healing. The Bates-Jensen Wound Assessment Tool (BWAT) is comprised of fifteen items, of which thirteen are scored from 1–5. The total scores and dates of assessment can be plotted on a graph, which provides an index of improvement or deterioration of the wound.

Another tool is the PUSH tool (Pressure Ulcer Scale for Healing), which was developed by NPUAP. An ulcer is categorized using numerical scores of 0–5 according to surface area (length times width), drainage amount, and tissue type. A comparison of the total scores measured over time provides an indication of improvement or deterioration in the ulcer.

Many computer systems also have programs to monitor ulcer progress. Of course, the clinician will also use clinical judgment to assess signs of healing, such as a decrease in the amount of drainage, pain, and wound size, and an improvement in wound bed tissue. The clinician can also use photography, comparing baseline and serial photographs to monitor healing over time. Follow facility policy on the use of photography.

Factors That Affect Wound Healing

If the choice of wound care is appropriate and pressure is being relieved, then the patient needs to be reassessed for reasons why the ulcer is not improving. One systematic approach to determining which factors might be affecting wound healing utilizes the acronym DIDN’T HEAL. Using this acronym and correcting those factors that can be corrected will aid in healing the ulcer. If factors cannot be corrected, healing the ulcer may not be possible.

DIDN’T HEALCause Description Additional Factors

Source: Stillman, 2010.

Diabetes

Lack of diabetic control affects wound healing by causing diminished cardiac output, poor peripheral perfusion, and a decrease in the ability of WBCs to function

Fasting blood sugar greater than 80–120 mg/dl

A1C greater than 6.5%

InfectionIncreases the destruction of collagen needed for repair

Overwhelms body defenses

DIDN’T HEALCause Description Additional Factors

Drugs Can impair collagen synthesis

Steroids

Chemotherapy (high risk for infection/malnutrition)

Immunosuppressants (interfere with healing)

NutritionDeficiencies impair normal wound healing

Diet lacks adequate calories, protein, vitamins

Obese patients not necessarily well-nourished

Tissue necrosis

Impairs wound healing due to lack of oxygen

Cell death as a result of all the factors

Hypoxia Inadequate tissue oxygenation

O2 saturation less than 92%

Anemia

Poor circulation

Comorbid conditions such as heart failure, pneumonia, CVA

PainExcessive tension

Tension on wound edges leads to local tissue ischemia and necrosis

When the patient is moved, wound is pulled

Another wound

Competition for all the factors needed for wound healing impairs wound healing at all sites

Increased nutritional needs

Low temperature

Further deceases oxygen to the wound

Poor circulation

Use of cold cleansing solutions

Frequent dressing changes that cause wound temperature to drop to room temperature

Determining the Need for Surgical Intervention

A patient with a Stage III or IV ulcer may be evaluated for the need for operative repair for an ulcer that has not responded to conservative medical treatment. Prior to surgery the patient should be in an optimal state both mentally and physically, and factors that impair healing should be minimized. The patient’s ability to tolerate the surgery and participate in the postoperative rehabilitation must be assessed prior to any surgery. Some patients may not be surgical

candidates due to malnutrition, immobility, poor compliance with treatment, or other chronic diseases.

Operative procedures may include skin grafts or flaps (surgical reconstruction). Which option is available may be limited due to previous surgeries, a shortage of available tissue to use, and impaired blood supply. Immediately after surgery, the operated region must be totally offloaded. Once the surgical incision has healed, the patient will be allowed to gradually apply pressure to the area.

Rates of surgical complications and recurrence rates are high. Complication rates have been reported as high as 49%. Osteomyelitis is the major cause of breakdown after surgery (WOCN, 2010).

Documenting the Wound Status

The very basics of documentation are to document what was observed, what was done (including education provided), and how the patient responded. Documentation for pressure ulcer management includes an assessment of the ulcer on admission and at least weekly (or per agency regulations) for any signs of skin and/or wound deterioration, along with documentation of risk assessment and patient/family education provided. The following is also documented:

Onset, course, and duration of the ulcer Description of the ulcer

Pain: location, intensity, quality, onset, duration, alleviating/aggravating factors

Patient/caregiver’s ability and willingness to adhere to the prevention and treatment program

The description of the ulcer includes the physical characteristics of the ulcer itself and of at least 4 cm of the surrounding tissue (Hess, 2005). The following should be included in the documentation of any wound:

WOUND DESCRIPTIONCategory Description

Anatomic Location

Describe where on the body the wound is, including the nearest bony prominence or anatomic landmark. Descriptors such as anterior-posterior, medial-lateral, proximal-distal can clarify location.

Stage Use the staging definitions described above.Drainage or Exudate

Amount Light or scant

Moderate

Heavy or large

Copious

WOUND DESCRIPTIONCategory Description

Color

Serous (clear, watery plasma)

Sanguineous (bloody)

Serosanguineous (plasma and red blood)

Purulent (thick, odorous, possibly yellow, green, or brown)

Odor

Defines the presence or absence of high bacteria counts in the ulcer and should be assessed only after cleaning the wound. A strong or foul odor suggests infection. A mild odor may be due to the particular wound care products in use.

Description of the Periwound Skin

ColorRedness, pallor, blanchable erythema, nonblanchable erythema, purple discoloration

TemperatureWarmth may indicate further tissue breakdown or underlying infection.

IndurationAbnormal firmness with a definite margin may indicate infection.

MacerationSoftening of tissues may be due to soaking from wound drainage or contact with urine and/or stool.

DenudedSuperficial skin loss may be due to drainage or trauma (such as from tape). Excoriation refers to linear scratch-like marks, not to skin loss from trauma or incontinence.

Type of Tissue Exposed (appearance of wound bed)

Red

May indicate clean, healthy granulation tissue. Granulation is a pink or red moist tissue composed of new blood vessels and connective tissue that fills an open wound when it starts to heal. It usually has an irregular, granular surface. Not all red tissue is granulation.

Yellow

May indicate the presence of drainage or slough. Slough is a soft, moist, avascular (lacking blood supply) tissue that may be yellow, white, tan or green. It may be loose or firmly attached. Sometimes resembles chicken fat.

Black

May indicate the presence of eschar or necrotic tissue, which slows healing and allows bacteria to grow. It may be brown or tan and can be hard or soft, loose or firmly attached. It can resemble a scab, but there is no healing occurring under it.

Wound Measurements

Always use a single-use, metric tape measure. Never measure using “coins” (dime-sized, quarter-sized, etc.)Length Linear distances from wound edge to wound edge. To measure

consistently, look at the wound as if it were a clock face: the top of the wound (12 o’clock) is toward the patient’s head. The bottom of the wound (6 o’clock) is toward the patient’s feet. Length is the longest distance measured from 12 to 6 o’clock.

WOUND DESCRIPTIONCategory Description

WidthWidth is longest distance measured from side to side, or from 9 to 3 o’clock.

Depth

The distance from the visible surface to the deepest point in the wound base. Measure depth using a cotton-tip applicator, holding it perpendicular to the wound edge, placing the finger at the point on the swab that corresponds to the wound edge. While still holding this measurement, remove the swab and measure it on the tape measure.

Undermining

Tissue destruction to underlying, intact skin along the wound edges. Use a cotton-tip applicator to probe to the deepest part of the undermining. Mark the depth between the end of the applicator and the wound edge with the finger and measure it against the tape measure. Describe the location of the undermining using the clock face (e.g., “undermining extends from 12 o’clock to 5 o’clock and is deepest at 3 o’clock at 3 cm”).

Tunneling or Sinus Tract

A path of tissue destruction that occurs in any direction from the surface or edge of the wound. Measure the tract as for undermining and describe its location using the clock face.

Wound care documentation includes a variety of information that reflects the wound status while it heals. Providing an accurate description of the skin and wound characteristics is critical during each patient visit. These findings will help the clinician revise the plan of care and treatment strategies over time, based on the current status of the ulcer.

Minimizing the Recurrence of Ulcers

Achieving a closed wound is the beginning of the struggle to prevent an ulcer from recurring. Clinicians must emphasize to patients and caregivers that measures to promote healing and prevent recurrence are lifelong. Recurrence rates for adults have been reported as high as 56%, and 21% develop a new ulcer at a different site (WOCN, 2010). The most common factors associated with recurrence are related to a lack of compliance with maintaining a healthy lifestyle, such as stopping smoking, maintaining a normal weight, controlling blood sugars if diabetic, and offloading the pressure areas. Patient education regarding these factors is critical.