The 2016 NPUAP Pressure Injury Staging System · The 2016 NPUAP Pressure Injury Staging System...

The 2016 NPUAP Pressure Injury Staging System

Joyce Black, PhD, RN, CWCN,

FAAN

March 21, 2017

©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

The 2016 NPUAP Pressure Injury Staging System

Joyce Black, PhD, RN, CWCN, FAAN

3

Continuing Education Disclosures

Commercial Support or Sponsorship – None

Speaker or planner conflicts of interest – None

For Nursing credit or attendance certificate:

Full session attendance and completion of one on-line evaluation.

No products or services are endorsed by MetaStar or any accrediting agency.

Evaluation link –

https://www.surveygizmo.com/s3/3398124/March-21-2017-LSQIN-Pressure-

Injury-Definition-and-Stages-Changes-to-the-Staging-System-in-2016

The participant is responsible for determining if the educational activity is

acceptable to meet CE requirements to renew licensure in their state

Thank you!

https://www.surveygizmo.com/s3/3398124/March-21-2017-LSQIN-Pressure-Injury-Definition-and-Stages-Changes-to-the-Staging-System-in-2016































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Learning Objectives

• Following this webinar, participants will be

better able to:

– Describe the rationale for changing the term pressure

ulcer to pressure injury.

– Identify the changes in the 2016 NPUAP staging

system.

– Identify pressure injury prevention and treatment

strategies

Process

• Task force appointed in 2014 to review current

staging terms

• Laura Edsberg, Laurie McNichol, Margaret

Goldberg, Lynn Moore, Mary Siegreen and Joyce

Black

• Over 3000 papers reviewed

• Draft definitions sent out for review and comment

• Consensus meeting held April 2016

©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 5

Since April 2016

• Staging system endorsed by

– Wound, Ostomy and Continence nurses Society (WOCN)

– Centers for Medicare and Medicaid Services (CMS) for

upcoming work

– The Joint Commission

– World Health Organization for ICD-11

– Many health care organizations

– Many health care associations

• Except Association for the Advancement of Wound

Care (AAWC)

– Pointed negative statements about the use of the word

“injury”, the consensus process and even the task force

members


Why the word “injury”?

• Stage 1 and Deep Tissue Injury were never

ulcers

• An ulcer cannot be present without an injury, but

an injury can be present without an ulcer


Is there greater legal exposure?

• Legal cases on pressure injury/ulcer begin because:

– The patient or family has an expected outcome which

leads to frustration or anger

– The standard of care was not met

– The pressure injury was avoidable

– Cases are not brought forth because of their name


Does the word “injury” makes these cases more litigable? • We asked multiple malpractice attorneys

• We had no early concerns for the change by

stakeholders

• We have had no concerns expressed by those who

have endorsed the new terms

• No one knows

– The change from decubitus to pressure ulcer did not change

the case law


Publication


The Updated Staging System


Anatomy of the Skin

• Largest organ of the body

• When intact, serves as the

primary prevention from

invasion


12 9


Layers of the skin

• Epidermis - dry keratinocytes

• Rete pegs bind the two layers

• Dermis - living layer contains

nerves, vessels, lymphatics, hair

follicles

• Two layers

– Papillary (superficial)

– Reticular (deeper)

» Contains epidermal

elements that support

healing

13

Anatomy of the Skin

10

Pressure Injury Definition


• A pressure injury is localized damage to the skin and

underlying soft tissue usually over a bony prominence or

related to a medical or other device.

• The injury can present as intact skin or an open ulcer and

may be painful. The injury occurs as a result of intense

and/or prolonged pressure or pressure in combination with

shear.

• The tolerance of soft tissue for pressure and shear may also

be affected by microclimate, nutrition, perfusion, co-

morbidities and condition of the soft tissue.

• A pressure injury is localized damage to the skin and underlying

soft tissue usually over a bony prominence or related to a

medical or other device.

• The injury can present as intact skin or an open ulcer and may

be painful. The injury occurs as a result of intense and/or

prolonged pressure or pressure in combination with shear.

• The tolerance of soft tissue for pressure and shear may also be

affected by microclimate, nutrition, perfusion, co-morbidities and

condition of the soft tissue.


Pressure Injury Definition - changes

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

• Intact skin with a localized area of

non-blanchable erythema, which may

appear differently in darkly pigmented

skin. Presence of blanchable

erythema or changes in sensation,

temperature, or firmness may precede

visual changes. Color changes do not

include purple or maroon

discoloration; these may indicate deep

tissue pressure injury.

©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 16 13

• Pale or whitish areas on the skin as blood flow to

the region is prevented by a finger or plastic disc

(diascopy).


Blanch Response

14

• To determine blanching

− Apply light pressure for a few seconds

− Release and watch for quick return to usual skin color

• Blanchable

– Skin color returns immediately

• Non-blanchable erythema

– The lack of a blanche response

occurs when light pressure is

applied or, persistent redness in

lightly pigmented skin


Blanch Response

15

• Stage 1 Pressure Injury was discovered on tissue

that had been exposed to pressure in combination

with shear

• Patient was laying supine

when the injury pressure

injury occurred

• Pressure injury is located

on the buttocks rather than

the sacrum

• The linear mark is from a fold in the linen

19 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

Stage 1 Pressure Injury Example

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• Melanocytes in the epidermis

– Produce melanin pigment to absorb radiant energy

and protect the skin from harmful ultraviolet (UV)

radiation

• Causes of skin tone variations

– Sun exposure

– Gender

– Race

– Hormones

– Age


Pigmented Skin

17

• Intact skin with a localized area of non-blanchable

erythema, which may appear differently in darkly

pigmented skin.

− Pigmentation of the skin may

prevent visualizing the reactive

hyperemia in the pressure injury

− Moistening the skin will often aid

in visualizing color change

− Ask about pain in the area

− Palpate the skin for induration


Stage 1 in Darkly Pigmented Skin

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• Darkly pigmented skin does not

have a visible blanche response

• Examine the skin for other

changes indicating pressure

injury

– Discoloration compared to

surrounding skin

– Pain in the area

– Induration

22


Stage 1 Pressure Injury Example

19

• Partial-thickness skin loss with

exposed dermis. The wound bed is

viable, pink or red, moist, and may

also present as an intact or ruptured

serum-filled blister. Adipose (fat) is

not visible and deeper tissues are not

visible. Granulation tissue, slough

and eschar are not present. These

injuries commonly result from

adverse microclimate and shear in

the skin over the pelvis and shear in

the heel.


Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis

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• This stage should not be used to describe moisture

associated skin damage (MASD) including incontinence

associated dermatitis (IAD), intertriginous dermatitis (ITD),

medical adhesive related skin injury (MARSI), or traumatic

wounds (skin tears, burns, abrasions).

IAD ITD Skin Tear


Stage 2 Pressure Injury Definition

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• Appearance

– Shiny, red

– Visible blood vessels in

reticular layer

– Edge may be distinct in

thick tissue or beveled in

thin tissue

• Painful

• May have serious drainage


Characteristics of Viable Dermis

22

• Exposure of reticular

layer of dermis

– Capillary buds visible

– Can look like slough

– Is not removable

26

Paraplegic with thickened

skin due to slide transfers

creates a visible edge to

the ischial stage 2 injury

Appearance of Stage 2


Lateral Heel Thigh and Scrotum

from Medical

Device

Anterior Chest

from Prone

Position while in

Operating Room


Stage 2 Pressure Injury Examples

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Epithelialization

• Presence of epithelial

cells in dermis promotes

healing without a scar

and contracture

• Pigmentation seldom

returns


Stage 2 Pressure Injury Healing

25

• Full-thickness loss of skin, in which

adipose (fat) is visible in the ulcer and

granulation tissue and epibole (rolled

wound edges) are often present.

Slough and/or eschar may be visible.

The depth of tissue damage varies by

anatomical location; areas of

significant adiposity can develop deep

wounds. Undermining and tunneling

may occur. Fascia, muscle, tendon,

ligament, cartilage or bone is not

exposed. If slough or eschar obscures

the extent of tissue loss this is an

Unstageable Pressure Injury.


Stage 3 Pressure Injury: Full-thickness skin loss

26

• Epibole (ee-PIB-oh-lee)

• Rolled edge

– Due to lack of tissue in the wound bed to support the

epidermal cells to cross the wound bed

– Needs to be removed


Area of

Focus

30

Stage 3 Pressure Injury with Epibole

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Full thickness pressure injury

heals by:

• Granulation tissue

− Capillary buds

• Contracture

− May create epibole

• Epithelialization over

the scar

− Fragile for at least a year


Stage 3 Pressure Injury Wound Bed

28

Slough (sluf)

Eschar (ES’- car) Dried inflammatory fluids that

are moist, stringy; and yellow,

tan, gray, green or brown

Necrotic tissue that is

leathery or thick; and black,

brown or tan


Ulcer Surface Appearance


Ischium Sacrum Heel

33


30

Stage 4 Pressure Injury: Full-thickness loss of skin and tissue

• Full-thickness skin and tissue

loss with exposed or directly

palpable fascia, muscle, tendon,

ligament, cartilage or bone in

the ulcer. Slough and/or eschar

may be visible. Epibole (rolled

edges), undermining and/or

tunneling often occur. Depth

varies by anatomical location. If

slough or eschar obscures the

extent of tissue loss this is an

Unstageable Pressure Injury.


Tendon Bone Muscle



32

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss

• Full-thickness skin and tissue loss

in which the extent of tissue

damage within the ulcer cannot be

confirmed because it is obscured

by slough or eschar. If slough or

eschar is removed, a Stage 3 or

Stage 4 pressure injury will be

revealed. Stable eschar (i.e. dry,

adherent, intact without erythema

or fluctuance) on an ischemic limb

or the heel(s) should not be

softened or removed.


Unstageable Pressure Injury Examples


Unstageable Injury

on the Sacrum

Unstageable Injury

on the Lateral Heel

Unstageable on

the nasal bridge

from NIPPV

37 34

Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration

• Intact or non-intact skin with

localized area of persistent non-

blanchable deep red, maroon,

purple discoloration or epidermal

separation revealing a dark wound

bed or blood filled blister. Pain and

temperature change often precede

skin color changes. Discoloration

may appear differently in darkly

pigmented skin. This injury results

from intense and/or prolonged

pressure and shear forces at the

bone-muscle interface.


The wound may evolve rapidly to reveal the actual

extent of tissue injury, or may resolve without tissue

loss. If necrotic tissue, subcutaneous tissue,

granulation tissue, fascia, muscle or other underlying

structures are visible, this indicates a full thickness

pressure injury (Unstageable, Stage 3 or Stage 4).

Do not use DTPI to describe vascular, traumatic,

neuropathic, or dermatologic conditions.


Deep Tissue Pressure Injury

• Day 1 - Classify intact, discolored skin this pressure as a Deep

Tissue Pressure Injury

• Day 3 - Classify discolored skin with epidermal blistering as a

Deep Tissue Pressure Injury

• Day 10 - If the Deep Tissue Pressure Injury becomes necrotic,

classify it as an Unstageable Pressure Injury


Day 1 - DTPI Day 3 - DTPI Day 10 - Unstageable

Evolution of Deep Tissue Pressure Injury

• Due to the thickness of the skin, the epidermal

separation will remain intact for a longer

period of time. This phase can be mistaken

for skin tears.


Evolution of DTPI in Darkly Pigmented Skin

38

Deep Tissue Pressure Injury Definition

• Do not use Deep Tissue Pressure Injury (DTPI) to

describe vascular, traumatic, neuropathic, or

dermatologic conditions.

Traumatic

Bruising

Vasopressor

Ischemia Coumadin

Necrosis


Deep Tissue Pressure Injury Examples


Buttocks Lateral Heel

43 40

Medical Device Related Pressure Injury

• Medical device related

pressure injuries result from

the use of devices designed

and applied for diagnostic or

therapeutic purposes. The

resultant pressure injury

generally conforms to the

pattern or shape of the

device. The injury should be

staged using the staging

system.



Unstageable Deep Tissue

Pressure Injury Stage 4

Stage 2 Stage 3 Stage 1

Medical Device Related Pressure Injury Examples

Mucosal Membrane Pressure Injury

Mucosal membrane pressure injury is found on mucous

membranes with a history of a medical device in use at

the location of the injury. Due to the anatomy of the

tissue these ulcers cannot be staged.

There is no epidermis or dermis in this tissue

– Upper layer is epithelium

– Columnar cells produce mucus

– Laminar layer provides support


Add New

Artwork

46 43

Mucous Membrane Ulcers Examples

47 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

Tongue Injury from

Endotracheal tube

Lip Injury from

Endotracheal Tube

44

If More Than One Type of Tissue is Exposed

• Stage a pressure injury

according to the deepest

layer of tissue exposed,

i.e. adipose, muscle, bone

• If the extent of tissue

damage cannot be

confirmed because it is

obscured by slough or

eschar, then it is staged

as an Unstageable

Pressure Injury


Pressure Injury Staging

Before staging a pressure injury

• Determine that the cause of the injury

− Is the injury from pressure or pressure in

combination with shear?

− Is the injury from moisture associated skin

damage (incontinence associated dermatitis,

intertriginous dermatitis), medical adhesive

related skin injury or traumatic wounds (skin

tears, burns, abrasions).

• Cleanse the wound to remove any loose tissue

or other debris


• History of injury (if known)

– Date of discovery, including Stage

• Location

– Use anatomical terms

– Note medical or other device in use

• Measurements

– Length, width, depth, tunnels, undermining

• Wound characteristics

– Wound bed appearance, amount of drainage, odor,

periwound skin condition, etc.


Pressure Injury Staging: Additional Documentation

A Closer Look at Medical Device Pressure Injury


Medical Device Related Pressure Injury Examples


Unstageable Deep Tissue

Pressure Injury Stage 4

Stage 2 Stage 3 Stage 1

• Localized injury to the skin or underlying tissue as a

result of sustained pressure from a device (Black, 2010)

– Tissue injury mimics the shape of the device

– Tend to progress rapidly due to lack of adipose tissue

MDR Pressure Ulcer


Incidence

Cervical collars

Immobilzers

O2 tubing

Stockings/ boots

NG tubes

22%

17% 13%

12%

8%

Data from Apold, 2012)

Scope of the Problem


Location Device Non Device

Head/face/neck 70.3% 7.8%

Other/multiple 21.9% 5.8%

Heel/ankle/foot 20.3% 16.9%

Coccyx/buttocks 7.8% 67.5%

Sacrum 1.6% 16.9%

Extent of the Problem

Data from Apold and Rydrych, 2012


• 74 percent of MDRPrU were not identified until they

were a stage III, IV or unstageable

• 63 percent of cases had no documentation of

– Skin inspection

– Device removal q shift

– Pressure relief

Data from Apold and Rydrych, 2012

Extent of the Problem


Reducing MDRs- Trach collar/straps

• 66.7 percent of ulcers in skilled care

were due to trach ties (Jaul, 2011)

• Issues

– Airway is #1

– Face plate often sutured in

place

– Trach ties often tied tightly to secure trach

tube

– Ties lost in obese skin folds of neck

– Proxemics to major vessels can create fatal

erosion


Trach Collar Pressure Ulcers

• Prevention

– Work with MDs who place the trachs

• Can sutures come out after 5 days?

– Work with RT

• Frequency of securement device changes

• Change ties with trach care


Trach Collar Pressure Ulcers

• Prevention

– Nursing

• Use thicker, wider foam collar straps to pad skin

• Pad skin around stoma

• Check for ulcers beneath straps on each shift

• Look closely at securements in neck folds

• Find ties and move them daily

• Line entire neck with dressings

Silver dressings reduced ulcers and peristomal skin

injury (Kuo, 2013)


CPAP-BiPap Facial Ulcers

• Issues – Develop quickly due to thin

tissue

– Visible injury

– Device applied tightly to

maintain O2 sats

• Prevention – Work with RT to apply dressing prior to O2

– Bundle dressings to devices

– Line nasal bridge and cheeks with foam dressings before placement

– Switch to total face mask before 12 hours (Lemyze, 2013)


Oral Mucosal Pressure Ulcers

• Issues

– Airway is priority #1

– Severity underappreciated

• May not be seen as serious

since scar seldom develops

• Prevention

– Rotate device

• RT to help with ET tubes

• Move with each position change

– Check length before

securing

– Use securement devices that can

be loosened


Oxygen Tubing Ulcers

• Issues – Incidence up to 37 percent

– NC tends to move out of nares

• causes tightening of device

• Prevention – Inspect skin on each shift

– Educate patient to report discomfort

– Pad high risk areas

– Bundle device to O2 tubing

– Use silicone O2 tubing


Elastic Stockings

• Issues

– Should not be used on

patients with PVD!

– Fitted without measurement

– Fitted while patient is dry,

become tight with edema

• Prevention

– Measure first

– Remove daily-twice daily

to inspect skin

• Especially thighs


Cervical Collars

• Incidence (Davis, 1995)

– Days 0-4 = 33 percent

– Days over 5 = 55 percent

• Found on occiput, face, chin, chest

• Prevention

– Change to soft collar

– Ensure collar fit

– Assess skin (remove device)

– Pad occiput

• 89 percent reduction in PrU

(Jacobson, 2008)

– Change pads


NG Tube Ulcers

• Prevention

– Check placement of NG daily

• Can coil in posterior pharynx

– Change to soft feeding tubes when able

– Securement to be free floating in nare

– Move tube when head turned to the side


Genital MDR PrU

• Issues

– Tubing too short

– FMS designed with ridges

for support

• Prevention

– Use indwelling for urinary

monitoring only

– Intermittent cath preferred

– Check location of tubing with each reposition

• Leave slack in tubing

– Tape Foley to lower abdomen in males

• Prevents penile shaft tears


• Do we tell the product manufacturer of the

issue with MDR PrU?

• If so, what is the response?

– My experiences have been both positive and

negative

• Extension on neck collar

• Silicone oxygen tubing

• Revisions in Foley cath

• Reengineering of CPAP mask

The Role of Manufacturing


• NPUAP serves as the authoritative voice for

improved patient outcomes in pressure injury

prevention and treatment through public policy,

education and research.

NPUAP’s Role



Questions

This material was prepared by the Lake Superior Quality

Innovation Network, under contract with the Centers for

Medicare & Medicaid Services (CMS), an agency of the

U.S. Department of Health and Human Services. The

materials do not necessarily reflect CMS policy.

11SOW-MI/MN/WI-C2-17-248 032017

The 2016 NPUAP Pressure Injury Staging System · The 2016 NPUAP Pressure Injury Staging System...

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