27. Nutritional Needs 100% Death (pneumonia) 40% 50% Weakness, pneumonia poor healing, too weak to sit, no healing 30% 20% Impaired immune fx, Increased infection 10% mortality Complications % total weight loss
As you know the there is the epidermis, dermis, subcutaneous fat, muscle
And do this every 8 hours for the 1 st 24 hours. In ICU it should be each shift. Every patient needs a skin assessment form filled out on them. Take pictures- use a camera with a tape measure only or stick your finger in the picture (for perspective) Surgeons use the 7 days for principle for GI surgery, brain tissue, and myocutaneous flaps If devascularized or failure of anatomosis occur it will happen at that time. tissue and vascular failure will occur during this time.
Pressure ulcers have been an area of concern for the last 2000 + years. Skin is “the last a mummified body’s tissue is the last to desiccate.. Accounting for its presence in the body areas of little underlying tissue between bone and skin.” Paget gave lectures on bedsores in 1873 saying “pressure ulcers at times erupt from under intact skin The earliest type of classification was develop in 1955 by Guttman. But Shea in 1975 developed the first well documented staging system used in the United States basing the pressure ulcers on pathology this was used widely in the US until the late 1980’s When the wocn group developed the staging system in 1988. The NPUAP held it first consensus group 1989 and was only used fairly successfully for 18 years but was revised to include darker skin tones. NPUAP has been the leaders in defining and establishing guidelines for Pressure Ulcer protocol. Staging was designed to communicate about the depth of a pressure ulcer..
These stats will change since the revision since many other skin “afflictions have been included such as perineal dermatitis, tape tears, According to Lyder 2003, these are the stats currently.
The Skin remains in place but the underlying structures slides downward without skin moving. Patients with this type of pressure ulcer the sore will be irregular shaped, develop tunnels and undermining. This includes from stretcher to bed, transferring from bed to wheelchair or pulling someone up to the HOB Shear and friction are used interchangeable but they are not the same! The proper terminology is shear strain - the tissue becomes deformed as the body as the body tries to slide or move on a surface.
So what is moisture it is wet skin. This can occur from wound drainage, incontinence of urine or fecal, temperature or perspiration Chemical damage - fecal and urinary incontinence, wound drainage, harsh solutions (betadine or H202) Maceration- water logged skin, Incontinence creates excess moisture and chemical damage. Fecal incontinence adds detrimental effects by exposing the skin to bacteria and enzymes
The change was made to further define and clarify the difference of between suspected deep tissue injury and stage I. Remember deep tissue injury and stage I pressure ulcers are different ulcers and the outcomes for each will be different. The treatment may be the same initially. Stage I may be difficult to detect, in individuals with dark skin tones, This person “is at risk” the area is painful Cms will not be paid for hospital acquired pressure ulcers, majority of the patients can be managed by positioning off of area, get them on a support surface
The previous stage II definition contained language that included other skin disorders- such as tape burns, perineal dermatitis and other non pressure ulcer injury. The wound bed should be pink or red NO purple or discolored and no slough. I can tell you that several perineal dermatitis and other skin disorders have been added to prevalence rates due to the old definitions.
It has been my opinion, if you had a stage III just call it a stage IV under the previous definition but this definition further clarifies the stage III. This again will allow for further accuracy in identification and reporting.
The further description gives further clarification for the practitioner on the staging .
The addition of this definition makes my heart sing! It further clarifies the definition and furthers classifies what you see when evaluating a patient. The definition is clearer and cleaner than the “work in progress” over the last 5 years.
This definition was not in the original staging classification. This type of ulcer has been an unidentified but reported over the years. Most deep tissue injury take 7 days to demarcate, by day 9 to 11 spontaneous skin slippage occurs and 14 to 15 days to form eschar.
