Pressure Ulcer Assessment and ClassificationResources for Nursing
July 19, 2013 — 1,666 views
Also known as bedsores or decubitus ulcers, pressure ulcers are injuries to the skin or the tissue underneath it. These injuries result from extended periods of pressure or pressure accompanied with shear and friction. 67% of all pressure ulcers show up in patients aged 70 and above. However, anybody who is in a condition where avoiding prolonged periods of pressure on a certain body part is not possible, is at the risk of contracting the pressure ulcer.
Assessment of Pressure Ulcers
Soft tissues, when under a lot of pressure or pressure for an extended period of time, undergo complete or partial obstruction of the flow of blood. Shear may also cause obstruction of blood flow by straining or stretching the blood vessels under the skin.
Bony appendages on the body are more prone to pressure ulcers. Those on the hip and buttock areas alone account for two thirds of total pressure ulcers. Another 25% of total pressure ulcers occur frequently on the lower extremities of the body – heels, patellar, or malleolar locations.
Classification of Pressure Ulcers
The National Pressure Ulcer Advisory Panel currently defines four stages of pressure ulcers depending on the extent of damage. These are as follows:
Stage I – This stage of pressure ulcers is marked by intact skin having a nonblanchable erythema typically over a bony prominence. This stage may go undetected in people with a pigmented skin tone. Pain, higher or lower temperatures, and abnormal firmness or softness of the area are other symptoms of stage 1 pressure ulcers.
Stage II – Pressure ulcers in this stagehave a fractional thickness loss of the epidermis, dermis, or both. The affected area may be blistered – with or without serum or look like a burnished or dry shallow ulcer containing no slough.
Stage III – This stage is marked by loss of entire thickness of skin. The subcutaneous fat is visible in this stage. But bones, tendons, and muscles don’t get exposed. Depending on the amount of subcutaneous fat the affected area has, stage III ulcers can get extremely deep or remain shallow. Undermining and tunneling of the affected area is possible and so is the presence of slough.
Stage IV – This stage is characterized by the loss of full thickness tissue such that the muscle, tendon, or bone under the area comes in plain sight. These supporting structures may even suffer extensive damages and necrosis, accompanied by undermining and tunneling in the affected area. Similar to stage III ulcers, the analytical location and amount of subcutaneous fat determines the depth of the sore.
In some cases it may not be possible to comprehend the correct stage of the ulcer due to eschar or slough concealing the actual depth of the full thickness loss of tissue. In such cases it is advisable to make the wound visible by cleaning out suitable amounts of the eschar or slough. The stable eschar present on the heels should not be removed for it serves as a natural cover for the body and should remain intact.
Pressure ulcers when interlaced with osteomyelitus or cellulitis must be treated with suitable antibiotics. Patients who show clinical signs of sepsis in their pressure ulcers would need immediate medical care.