Wound Staging and Dressing Choices

Wound Staging and Dressing Choices

woundcareresourcenetwork.com | info@woundcareresourcenetwork.com
Disclaimer The information presented in this presentation constitutes an introduction to a topic that has been prepared and provided for educational and informational purposes only. It is for the attendees general knowledge and is not a substitute for legal or medical advice. Legal and or medical advice requires appropriate licensure, expert consultation and an in-depth knowledge of your situation. Although every effort has been made to provide accurate information herein, laws and precedents are always changing and will vary from state to state and jurisdiction to jurisdiction. As such, the material provided herein is not comprehensive for all legal and medical developments and may advertently contain errors or omissions. This review, we hope, will give a starting point for thinking about the way you practice wound care in that you begin to understand the need for thorough knowledge and careful documentation about the care of the patients. Wound Care Resource Network llc shall not be held liable for any situation that may result directly or indirectly from use or misuse of this information. woundcareresourcenetwork.com |

Objectives Review pressure ulcer staging guidelines Discuss documentation and MDS Review dressing selection Review measuring techniques Questions and answers woundcareresourcenetwork.com |

Definitions Related to Pressure Ulcers
Staging system Identify pressure ulcers by the tissue layer involved. Anatomic description of wound depth. NPUAP Suspected Deep Tissue Injury Stage I Stage II Stage III Stage IV Unstageable Should only be used on wounds caused by pressure! The NPUAP recently revised its definitions for pressure ulcers (Stages 1-4) and added two new stages; Suspected DTI and Unstageable. These were released 2/07 and are available at GIVE NPUAP HANDOUT! PROVES WE DIDN’T MAKE THIS UP! woundcareresourcenetwork.com |

Suspected Deep Tissue Injury
Suspected Deep Tissue Injury: New to NPUAP Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of 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. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. 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. Important to use the word “suspected” to prevent “diagnosing” which is incumbent upon the MD. We will discuss this in more detail. woundcareresourcenetwork.com |

Stage I Stage I: Nothing changed Intact skin with non-blanchable 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. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk) woundcareresourcenetwork.com |

Stage II Partial thickness skin loss Epidermis and superficial dermis only Superficial and presents as an abrasion, serous blister, or shallow crater Stage II: Nothing changed Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury. woundcareresourcenetwork.com |

Stage III Full thickness skin loss Epidermis, dermis, subcutaneous tissue Does not pass through the fascia Presents as a deep crater with or without undermining of adjacent tissue Stage III 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. 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 these ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Note the difference in the depth of the wounds. The wound on the top is larger and deeper. However, the wounds on the bottom are STILL full thickness, no matter the size. BIG CHANGE! NPUAP CLARIFIED THAT IF ANY NECROTIC TISSUE IS PRESENT, IT HAS TO BE STAGED III. If you are describing the wound color as anything besides pink, red, 100% viable, you must stage it a III. Surveyors are looking for this. woundcareresourcenetwork.com |

Stage IV Full thickness skin loss Epidermis, dermis, subcutaneous tissue, may include muscle, bone, or tendon Tunneling or sinus tracts may be present Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (fascia, tendon, joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. woundcareresourcenetwork.com |

Unstageable Unstageable: New Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed. woundcareresourcenetwork.com |

Deep Tissue Injury (DTI)
Tissue injury that appears as dark discoloration, deep bruising, hematoma Borders are irregular and not well demarcated Typically acute formation Long OR times Falls Splints Single episode of pressure Misunderstood as Stage I Commonly referred to as “purple pressure ulcers” woundcareresourcenetwork.com |

Deep Tissue Injury Damage to deeper structures has already occurred Skin may still be intact because of its higher resistance to hypoxia Heralding sign of an impending stage III or IV woundcareresourcenetwork.com |

Deep Tissue Injury woundcareresourcenetwork.com |

Deep Tissue Injury

DTI Progression First identified in January…resolved in June of the same year. Typical location and progression of DTI. Heels are difficult areas to manage! woundcareresourcenetwork.com |

Management / Treatment of DTI
Complete and immediate pressure relief No massage to affected area Protect from other factors i.e., incontinence, friction, shear May use dry dressing if desired but no topical until “declared”* Monitor closely for deterioration Nutritional support *Some clinicians prefer to cover the area involved to provide “visual protection” for family members (not to hide the area but to prevent discomfort on the part of family and friends). Topicals (outside of skin prep) should not be used until the wound has declared itself…does the eschar become unstable? Then consider topical management… woundcareresourcenetwork.com |

Documentation NPUAP revised staging system includes suspected DTI Some Surveyors are stating the best MDS choice when it presents with intact skin is a Stage I However, because DTI is technically unstageable, according the MDS guidelines this would be coded as a Stage IV DTI is generally “unstageable” as the wound base is not visible, also not currently an MDS option NPUAP recommends: “Pressure-related deep tissue injury under intact skin” or “Deep tissue injury under intact skin” Include risk factors, interventions, turning schedule, etc. Code properly for MDS, then describe clinical findings. “Suspected DTI coded as a Stage IV pressure ulcer on the MDS. Surveyors are being taught that you MUST stage INTACT SKIN as MDS M1 (which is a pressure ulcer) and should be coded as a Stage I pressure Ulcer Make a separate column and further describe what you see as stated above… woundcareresourcenetwork.com |

Dressing Considerations for PU’s
Ask yourself Is the wound clean and free of infection? Is the wound dry or wet? These questions will guide your selection of dressings, topical medications and possible use of modalities Consider cost-effectiveness in treatment planning (minimize pt and wound disruption, care giver time, etc.) Caution: Inappropriate use of dressings can cause harm (dehydration, maceration, hypergranulation, reinjury, granuloma, skin stripping, contact dermatitis, etc.) Dry wound…add moisture Wet wound…absorb moisture Striving for a moist wound bed with a dry and intact periwound woundcareresourcenetwork.com |

Moist Wound Healing Standard of care for wound management Enables body to heal at peak efficiency Allows for improved epithelial migration Contraindicated in clinically infected wounds* At times, not the method of choice (wound etiology, goals, etc.)** *Every patient and patient situation is different. At times, moist wound healing can be used with an infected wound when the underlying cause of the infection is being addressed (topical and/or systemic antibiotics) and with regular and frequent re-assessment. **There are instances when moist wound healing may not be appropriate. For example, a dry stable heel ulcer covered with non-fluctuant eschar should remain DRY…no dressings or topicals needed unless the ulcer begins to drain, becomes soft/boggy or lyses. (Skin preps are OK and if a dry dressing is used to cover the wound to protect it from being visually disturbing to the patient or family member, this is OK as well.) In addition, moist wound healing should not be implemented on patients with dry gangrene for whatever reason (peripheral vascular disease, arterial insufficiency) UNLESS those ulcers begin to lyse or change warranting aggressive intervention. Dry gangrene must remain dry! The body will eventually auto-amputate the area. Swabbing the dry gangrene with betadine or using cadexamer iodine can assist with maintaining dry and stable gangrene. Beginning moist wound healing will open a Pandora’s box and could lead to septicemia, bacteremia, loss of limb or patient demise. Lastly, there are instances where complete wound closure and/or wound healing are not appropriate goals (palliative care, hospice, etc). For these individuals, wound management goals should address quality of life: comfort, odor management, and protection from infection or wound progression. In such cases, moist wound healing may or may not be appropriate. woundcareresourcenetwork.com |

Moist Wound Healing Advantages reduced wound pain decreased edema
rapid healing better cosmetic results softens eschar facilitates autolytic debridement creates environment at near physiological temperature to optimize phagocytosis easy to implement fewer dressing changes cost effective excludes environmental bacteria some dressings are waterproof some dressings can be used to reduce friction/shear forces

When to keep a wound dry? DTI Stage 1 Stable black eschar/unstageable on heels or toes Closed pressure ulcer Dry gangrene Ask someone to describe Stable and Unstable. woundcareresourcenetwork.com |

Stage I Pressure Ulcer Development and Progression High pressure for a short duration; low pressure for a long duration Reversible with appropriate intervention Management Implement pressure redistribution protocols Offloading Frequent repositioning Protect from friction, shear and moisture Can be left OTA or with a DPD May need to reposition every 50 minutes to 60 minutes instead of q 2hrs. Turning and positioning Q2hr is a standard of care for residents withOUT PU’s. If a PU develops the residents skin is not tolerating Q2hr and it must be adjusted. woundcareresourcenetwork.com |

Dressing Categories Calcium Alginates Transparent Films Foams Hydrogels Hydrocolloids Gauze Dressings Collagens Composite Dressings “New” Technologies Primary dressing The dressing that comes into contact with the wound bed Secondary dressing The dressing used to cover and protect the primary dressing Other categories include: biosynthetics, contact layers and specialty absorptives. These are primarily used in burn wound management. woundcareresourcenetwork.com |

Calcium Alginate Seaweed derivative Rope or pad Can absorb up to 20 times its weight in fluid For moderately to heavily draining wounds Biodegradable Also available: collagen alginate combining the effects of both dressing categories. woundcareresourcenetwork.com |

Calcium Alginate Advantages absorbent, filler biocompatible with periwound tissue no trauma to wound bed with removal facilitates autolytic debridement cost-effective Disadvantages more expensive if used improperly cannot visually monitor wound “gel” can sometimes be mistaken for infection not for use on desiccated wounds woundcareresourcenetwork.com |

Calcium Alginate Top wound – s/p infected ilio-fem bypass graft. Using calcium alginate in conjunction with Accuzyme in the photo. Moderate to heavy drainage. Bottom wound – note the exudate (no-wound is not infected) when expressing fluid in the undermined areas. woundcareresourcenetwork.com |

Transparent Films Adhesive Polyurethane membrane Semi-permeable As a group, waterproof and create a bacterial barrier Moisture Vapor Transfer Rates (MVTR) Loss of water vapor from intact skin is 240 – 1920 g/m2/24 hours Loss of water vapor from an open wound, g/m2/24 hours Different dressing types…different MVTR The more occlusive the dressing, the lower the MVTR Gauze has a very HIGH MVTR Advanced products have “GOOD” MVTRs or low MVTRs woundcareresourcenetwork.com |

Foams Can be either a cover dressing or a filler With or without an adhesive border Varying thickness and absorptive capabilities May have a polyurethane film coating woundcareresourcenetwork.com |

Foams Advantages good/excellent absorption good MVTR good O2 permeability min/no trauma to granulation tissue supports autolytic debridement Disadvantages no direct visual monitoring of wound may desiccate wound may require secondary dressing not for wounds with dry eschar woundcareresourcenetwork.com |

Foams As Primary Dressings Left wound – mixed etiology wound. Moderate drainage. Right wound – very painful to touch, moderate drainage. Need a dressing that will be atraumatic on removal and absorb drainage. Foams as primary dressings can only be changed 3X per week. woundcareresourcenetwork.com |

Foams Left wound – infected, moderate drainage – but using a primary dressing that promotes debridement. Right wound – using calcium alginate, enzymatic debrider, and cover with a foam. Foams as secondary dressings can be changed at the same frequency as the primary dressing. As Secondary Dressings woundcareresourcenetwork.com |

Hydrogels Water or glycerin based gels Variety of forms: sheet, amorphous, or impregnated gauze Add moisture to wound bed woundcareresourcenetwork.com |

Hydrogels Advantages good MVTR facilitates autolysis soothing good biocompatibility with periwound tissue no tissue trauma hydrates wound bed Disadvantages will dehydrate if not covered poor/fair exudate absorption can macerate periwound tissue require secondary dressing woundcareresourcenetwork.com |

Hydrocolloids Composition varies - gelatin, pectin, carboxymethylcellulose Variety of sizes, shapes and forms (pads, pastes, powders) Occlusive or semi-occlusive Some with high MVTR woundcareresourcenetwork.com |

Hydrocolloids Advantages bacterial barrier moderate exudate absorption decreases pain in wound facilitates autolysis self-adherent cost-effective Disadvantages dressing residue sometimes difficult to remove no visual monitoring of wound not indicated for infected wounds, tracts, or exposed tendon/bone adherent/tacky woundcareresourcenetwork.com |

Gauze Dressings Most variability of any product category Sterile vs. non-sterile Pads, fluffs, strips, rolls Impregnated with water, saline, or “other” With or without an adhesive border woundcareresourcenetwork.com |

Gauze Dressings Advantages mechanical debridement (non-selective) permeable fillers conformable adaptable combined w/ other dressings Disadvantages may be ineffective damage viable tissue painful removal dehydrate wound permeable to bacteria macerate may not be cost-effective woundcareresourcenetwork.com |

Collagens Typically derived from bovine collagen Promotes granulation tissue formation Stimulates new tissue development and autolytic debridement woundcareresourcenetwork.com |

Collagens Advantages absorbent facilitates autolytic debridement moist environment nonadherent easy application facilitates wound healing may be used in combination with topical agents biodegradable Disadvantages not recommended for full thickness burns not recommended for black, dry wounds (adherent eschar) requires secondary dressing woundcareresourcenetwork.com |

Composite Dressings Combine two physically different components into one dressing Features MUST include: bacterial barrier absorptive layer other than alginate, foam, hydrocolloid, or hydrogel a semi- or non-adherent wound covering Borders on composites may be adhesive or non-adhesive woundcareresourcenetwork.com |

Composite Dressings Advantages facilitates autolytic debridement safe with infected wounds easy application and removal can be primary or secondary dressing Disadvantages requires intact/healthy skin border woundcareresourcenetwork.com |

Amount of Drainage Slight Heavy Hydrocolloid Calcium Alginate Hydrogel
Gauze Thin Film Hydrofiber Collagen Foam When used as primary Primary Dressing Choice woundcareresourcenetwork.com |

Dressing Summary What do you want the dressing to do? Where is the wound located? During a dressing change, si the wound wet, moist or dry? Is the wound clean or infected? What tissues are present in the wound? Granulation, slough, eschar, deep tissue structures How painful is the wound and surrounding tissues? What is the quality of the periwound? What are your wound management goals? What are the patients/family members goals? Each patient and each wound will present uniquely. Document objectively and be able to justify your dressing choices. woundcareresourcenetwork.com |

CMS Guidelines: A Review of the Minimum Requirements
Assessment Mandated daily monitoring Mandated weekly or dressing change monitoring From the F413: “For those pressure ulcers with significant exudate, management of the exudate is critical for healing. A balance is needed to assure that the wound is moist enough to support healing but not too moist to interfere with healing. Since excess wound exudate generally impairs wound healing, selecting an appropriate absorptive dressing is an important part of managing chronic wound exudate. Product selection should be based upon the relevance of the specific product to the identified pressure ulcer(s) characteristics, the treatment goals, and the manufacturer's recommendations for use. Current literature does not indicate significant advantages of any single specific product over another, but does confirm that not all products are appropriate for all pressure ulcers. Wound characteristics should be assessed throughout the healing process to assure that the treatments and dressings being used are appropriate to the nature of the wound. Present literature suggests that pressure ulcer dressing protocols may use clean technique rather than sterile, but that appropriate sterile technique may be needed for those wounds that recently have been surgically debrided or repaired… Some facilities may use “wet to dry gauze dressings” or irrigation with chemical solutions to remove slough. The use of wet-to-dry dressings or irrigations may be appropriate in limited circumstances, but repeated use may damage healthy granulation tissue in healing ulcers and may lead to excessive bleeding and increased resident pain. A facility should be able to show that its treatment protocols are based upon current standards of practice and are in accord with the facility’s policies and procedures as developed with the medical director’s review and approval.” woundcareresourcenetwork.com |

Protocol for Assessment
Differentiate type of ulcer (pressure related versus non-pressure related) Determine stage (if pressure) or depth of tissue involvement for non-pressure related ulcers (partial or full-thickness) Describe and monitor the ulcer’s characteristics Monitor the progress toward healing and potential complications Determine if infection is present Assess, treat, and monitor pain Monitor dressings and interventions woundcareresourcenetwork.com |

Mandated Daily Monitoring
Evaluation of ulcer if no dressing is present Evaluation of the status of the dressing, if present Is it intact? Is there drainage? Is it leaking? Status of the peri-ulcer area Area around the ulcer that can be observed without removing the dressing Presence of possible complications Increased redness, swelling, drainage… Whether pain, if present, is being adequately controlled woundcareresourcenetwork.com |

Mandated Weekly or Dressing Change Monitoring
Size, depth, and the presence, location and extent of undermining or tunneling/sinus tract Exudate if present: type, color, amount, odor Pain if present: nature and frequency Wound bed: color and type of tissue Evidence of healing or necrosis? Description of wound edges and periwound Rolled edges, erythema, induration, maceration? woundcareresourcenetwork.com |

Factors to Document Classification/etiology Anatomic location Size (LxWxD in cm, include undermining and tunneling when present) in CM Appearance Drainage Pain, tenderness, itching Temperature Description of periwound These are some of the main wound characteristics that need to be documented and we will discuss each one in depth. woundcareresourcenetwork.com |

Wound Measurement Length & Width Linear distances from wound edge to wound edge Wound → think of a clock Top (toward patient’s head) = 12 o’clock Bottom (toward patient’s feet) = 6 o’clock Length measured 12 → 6 Width measured 3 → 9 Tracing After correctly classifying the wound, you should document WHERE the wound is located. You need to be as specific as possible. For example: Right lateral malleolus; left greater trochanter. If you just write “buttock” – where is that? OR – what if the patient has more than one wound located close together? How do you distinguish between those wounds? Right anterior shin proximal; right anterior shin distal… All wounds are measured as linear distances from wound edge to wound edge. If there is a large ulcer, with some minor skin breakdown around the edges, you STILL include that in the measurement of the wound. Also, you should consider that you are looking at the wound, like you would look at the face of a clock. The “top” of the wound is always toward the head (which would correspond to 12:00. The “bottom” of the wound is always toward the feet (which is 6:00). Then, left and right would correspond to 3:00 and 9:00 as well. The most accurate method of determining the overall size of the wound is to do tracings of the wound – but that can be time intensive. woundcareresourcenetwork.com |

Wound Measurement Depth Distance from visible surface to deepest point in wound base For pressure ulcers also document depth of tissue loss by appropriately staging the wound Wound Volume - alternative method to measuring a wound cavity Most facilities won’t use volumetric measurements – but the way that you would do this would be to take a syringe filled with saline and fill the wound to the top with saline. Then count the number of cc’s or mls it took to fill the cavity. This is NOT the most reliable method. woundcareresourcenetwork.com |

Wound Measurement Tunneling A single pathway that may extend in any direction Potential for anaerobic bacteria and abscess formation Direction of Tunnel Refer to location of tunnel as time on clock Document the deepest sites where the wound tunnels Depth of Tunnel 1. Insert applicator, grasp applicator where it meets the wound edge, record measurement 2. Qtip method: put one into depth and one on intact wound edge and measure the difference woundcareresourcenetwork.com |

Wound Measurement Undermining Tissue destruction that occurs to the underlying intact skin adjacent to the wound margins. Formation of a “shelf” of healthy, intact tissue over an area of dead space and/or necrotic tissue. Direction of undermining Refer to direction of undermining as time on clock Measurement of undermining Document the deepest site where the wound undermines and use one measurement to record the area of greatest tissue destruction. Example: Circumferential undermining noted. Deepest at 4 o’clock measuring 3.5 cm. woundcareresourcenetwork.com |

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