3M Skin & Wound Care Pressure Ulcers

3M Skin & Wound CarePressure Ulcers 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Stageg I: Nonblanchable ErythemayIntact skin with non-blanchableredness of a localized area usuallyover a bony prominence. Darklypigmented skin may not havevisible blanching; its color maydiffer from the surrounding area.The area may be painful, firm, soft,warmer or cooler as compared toadjacent tissue. Stage I may bedifficult to detect in individuals withdark skin tones. May indicate “atatrisk” persons (a heralding sign ofrisk).Pressure Ulcer Descriptions from Pressure Ulcer Prevention & Treatment Clinical PracticeGuideline, NPAUP-EUAP. P 19-20.Images NPUAP copyright and used with permission.2 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Stageg II: Partial Thickness Skin LossPartial thickness loss of dermispresenting as a shallow open ulcerwith a red pink wound bed, withoutslough.g Mayy also present as an intactor open/ruptured serum-filled blister.Presents as a shiny or dry shallowulcer without slough or bruising.bruising * Thisstage should not be used to describeskin tears, tape burns, perinealdermatitis maceration or excoriation.dermatitis,excoriation*Bruising indicates suspected deeptissue injury3Pressure Ulcer Descriptions from Pressure Ulcer Prevention & Treatment Clinical PracticeGuideline, NPAUP-EUAP. P 19-20.Images NPUAP copyright and used with permission. 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Stageg III: Full Thickness Skin LossSubcutaneous fat may be visible butbone tendon or muscle are notbone,exposed. Slough may be present butdoes not obscure the depth of tissueloss. May include undermining andtunneling.tunnelingThe depth of a stage III pressure ulcervaries by anatomical location. Thebridge of the nosenose, earear, occiput andmalleolus do not have subcutaneoustissue and stage III ulcers can beshallow. In contrast, areas of significantadipositydi it can ddevelopl extremelytl ddeepstage III pressure ulcers. Bone/tendonis not visible or directly palpable.4Pressure Ulcer Descriptions from Pressure Ulcer Prevention & Treatment Clinical PracticeGuideline, NPAUP-EUAP. P 19-20.Images NPUAP copyright and used with permission. 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Stageg IV: Full Thickness Tissue LossFull thickness tissue loss with exposedbone tendon or muscle.bone,muscle Slough or escharmay be present on some parts of thewound bed. Often include underminingand tunneling.The depth of a stage IV pressure ulcervaries by anatomical location. The bridgeof the nose, ear, occiput and malleolus donot have subcutaneous tissue and theseulcers can be shallow. Stage IV ulcerscan extend into muscle and/or supportingstructures (e.g., fascia, tendon or jointcapsule)l ) makingki osteomyelitistliti possible.iblExposed bone/tendon is visible or directlypalpable.5Pressure Ulcer Descriptions from Pressure Ulcer Prevention & Treatment Clinical PracticeGuideline, NPAUP-EUAP. P 19-20.Image 1 Provided by 3M Skin & Wound Care Division 3M 2011. All Rights Reserved.1

3M Skin & Wound CareUnstageable:gDepth UnknownFull thickness tissue loss in whichthe base of the ulcer is covered byslough (yellow, tan, gray, green orbrown) and/or eschar (tan, brownor black) in the wound bed.Until enough slough and/or escharis removed to expose the base ofthe wound, the true depth, andtherefore stage,stage cannot bedetermined. Stable (dry, adherent,intact without erythema orfluctuance) eschar on the heelsserves as “th“the bbody’sd ’ naturalt l(biological) cover” and should notbe removed.6Pressure Ulcer Descriptions from Pressure Ulcer Prevention & Treatment Clinical PracticeGuideline, NPAUP-EUAP. P 19-20.Images NPUAP copyright and used with permission.Image 2 Provided by 3M Skin & Wound Care Division 3M 2011. All Rights Reserved.2

3M Skin & Wound CareSuspected Deep Tissue Injury:j y Depth UnknownFull thickness tissue loss in which thebase of the ulcer is covered byslough (yellow, tan, gray, green orbrown) and/or eschar (tan, brown orblack) in the wound bed.Until enough slough and/or eschar isremoved to expose the base of thewound, the true depth, and thereforestage cannot be determinedstage,determined. Stable(dry, adherent, intact withouterythema or fluctuance) eschar onthe heels serves as “the body’snaturalt l (biological)(bi l i l) cover”” andd shouldh ldnot be removed.7Pressure Ulcer Descriptions from Pressure Ulcer Prevention & Treatment Clinical PracticeGuideline, NPAUP-EUAP. P 19-20.Images NPUAP copyright and used with permission. 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Prevention Recommendations Risk assessment Assess patientAti t llevell off riski k ffor pressure ulcerl ddevelopmentlt usingi anappropriate risk assessment toolFrequency of risk assessment determined by facility risk assessmentpolicy and patient acuityDetermine individual care plan based on result of risk assessment Skin assessment CompleteCl t skinki assessmentt upon admissiond i i tto ffacilityilitRegular skin inspection per facility protocol Minimize pressurep Determine appropriate pressure redistribution support surfaceProvide turning and repositioning schedule according to overallpatient condition and type of support surface in use8 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Prevention Recommendations Minimize friction and shear Manage incontinence/moisture Management of nutrition and hydration needs Provide patient and family education9 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Treatment Recommendations Assessment Assess ulcer initially and at least weeklyAssess and document: Stage:Stbasedb d on a validatedlid t d pressureulcer classification system Location Size: length x width x depth Presence of undermining and/or tunneling Wound bed tissue: granular,granular nonviable tissuetissue, eschar Exudate amount, color, odor10 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Treatment Recommendations Wound Management Cleanse wound with each dressing change per facility protocolProvide debridement of nonviable tissue as appropriate Do not debride stable,stable hardhard, dry eschar in ischemic limbsDetermine appropriate topical wound care based on assessmentfindings to promote healingCConsultlt physicianh i i or woundd care specialisti li t tot evaluatel t woundsd ththattshow signs of infection or fail to progressConsider use of topical antimicrobial dressing if high bioburdensuspectedModify plan of care based on assessment findings11 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Treatment Recommendations Provide pressure redistribution Minimize friction and shear Manage incontinence/moisture Assessment and management of pain Management of nutrition and hydration needs Provide patient and family education12 3M 2011. All Rights Reserved.

3M Skin & Wound Care3M Wound Product Guide for Pressure Ulcer Treatment13 3M 2011. All Rights Reserved.

3M Skin & Wound Care3M Resources For further information on 3M Advance Wound Careproducts and solutions contact: Your 3M Skin Health Representative3M Health Care Customer Help Line 1-800-228-39573M Website www.3M.com/skinhealth14 3M 2011. All Rights Reserved.

3M Skin & Wound CarePressure Ulcer Managementg– Reference List National Pressure Ulcer Advisory Panel: www.npuap.org Pressure Ulcer Prevention & Treatment, Quick Reference Guide:www.npuap.org/Final Quick Prevention for web 2010.pdf Pressure Ulcer Prevention & Treatment, Clinical Practice Guideline:www.npuap.org/resources.htm AHRQ; National Guideline Clearing House:www guidelines gov/search/search aspx?term pressure ulcerwww.guidelines.gov/search/search.aspx?term pressure ulcer Wound, Ostomy, and Continence Nurses Society: www.wocn.org15 3M 2011. All Rights Reserved.

3M Skin & Wound Care Pressure Ulcer Prevention Recommendations Risk assessment A ti t l l f i k f l d l t i Assess patient level of risk for pressure ulcer development using an appropriate risk assessment tool Frequency of risk assessment determined by facility risk assessment policy and patient acuity Determine individual care plan based on result of risk assessment