Stage IV Pressure Ulcer
Source: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.
According to the NPUAP, it is also important to never reverse stage a wound. Pressure ulcers heal to a progressively more shallow depth; they do not replace lost muscle, subcutaneous fat, or dermis. A Stage IV ulcer cannot become a Stage III, Stage II or Stage I. When a Stage IV ulcer has healed, it should be classified as a healed Stage IV pressure ulcer (NPUAP, 2000). It should be noted that an ulcer should never be staged if uncertainty exists about the stage. Instead, it is recommended that the wound be described. In describing a wound, it is important to refrain from sizing a wound using dime or quarter sizing; the wound should always be measured. Further, wounds not related to pressure, including partial or full thickness skin loss and burns, are never staged.
Superficial skin damage can also occur when adhesive products are used with any pediatric patient (although the chronically ill and critically ill are at an even higher risk). A skin tear or epidermal stripping is a partial thickness wound, involving tissue loss of the epidermis and possibly the dermis (Bryant, 2000). It is the inadvertent removal of these layers by mechanical means, such as tape removal. A skin tear may present as a broad wound, similar to an abrasion or as a narrow tear in the epidermis. It may be dry with little or no drainage, or have moderate drainage, depending on the location and the extent of epidermal involvement. Some skin tears also will have a viable skin flap; the treatment goal should be to avoid dislodging the flap. The flap should be positioned in an area that optimizes its chances of re-adhering to the wound bed. Dressing choice is important; a dressing should be used that will not stick to the area, such as a hydrogel. If the surrounding skin also is fragile, a dressing without an adhesive border should be considered and secured with a gauze roll. In patients where there is good surrounding skin integrity, a transparent film can be used if little or no drainage is present.
Skin tears or epidermal stripping, as well as tension blisters, can easily be avoided by proper skin preparation, choice of tape, and proper application and removal of tape. Stripping can occur when the adhesive bond between tape and skin is greater than between epidermis and dermis. As tape is removed, the epidermis remains attached to the tape, resulting in painful damage. Tension blisters are the result of tightly strapping the tape during application and distention of the skin underneath. Strapping is mistakenly thought to increase adhesion; however, as the tape resists stretching, the epidermis begins to lift, resulting in a blister at the end of the tape.
A key component to the prevention of skin tears/stripping is to recognize fragile, thin, vulnerable skin (Bryant, 2000). Careful and gentle care is important in routine patient care because most skin tears occur during this time. In addition, the current focus of prevention is on the application of products to serve as a barrier. Skin tears resulting from adhesion can be prevented by appropriate application and removal of tape, use of solid wafer skin barriers, thin hydrocolloids, low-adhesion foam dressings or skin sealant under adhesives, use of porous tapes, and avoidance of unnecessary tapes.
Wound Treatment
The key to properly treating a wound is having a basic sense of the wound healing process and understanding the various products available. For example, moist wounds heal faster than dry wounds. It is easier for a wound in a moist environment to granulate and for the cells to migrate across the wound bed. A moist environment also increases the effectiveness of white blood cells in fighting infection and removing cellular debris (Bryant, 2000). However, if a wound is draining heavily, an appropriate dressing should be used to contain the drainage.
Dressings can be categorized into four types: primary, secondary, occlusive, and semi-occlusive. A primary dressing is one that comes directly in contact with the wound bed. A secondary dressing is used to cover a primary dressing when the primary dressing does not protect the wound from contamination. Occlusive dressings cover a wound from the outside environment and keep nearly all moisture vapors at the wound site. And finally, a semi-occlusive dressing allows some oxygen and moisture vapor to evaporate through the dressing. For a sampling of dressings and their characteristics, see Table 2 .
Nursing Implications
According to clinical practice guideline number 15, set forth by the U.S. Department of Health and Human Services (1994), institutions should design, develop, and implement educational programs to address prevention and treatment of pressure ulcers for patients, caregivers, and healthcare providers; these programs should reflect a continuum of care. Adequate involvement of the patient and caregiver, when possible in treatment and prevention strategies, is highly recommended. In the pediatric population, depending on age, it is not always possible to involve the patient; however, the parents should be involved. In particular, in the critical care environment, involving parents and caregivers can provide a sense of involvement in the care of the child, reducing the sense of powerlessness sometimes experienced by parents of critically ill children. Further educational programs should identify those responsible for pressure ulcer treatment, providing a clear description of each person's role in the treatment process.
An educational program should emphasize the need for accurate, consistent, and uniform assessment, and documentation of the extent of tissue damage. The clinical practice guidelines on the treatment of pressure ulcers suggest a comprehensive educational program. Information in a educational program on the treatment of pressure ulcers should include (a) etiology and pathology, (b) risk factors, (c) uniform terminology for stages of tissue damage based on specific classifications, (d) principles of wound healing, (e) principles of nutritional support, (f) individualized programs of skin care, (g) principles of cleansing and infection control, (h) principles of postoperative care, including positioning and support surfaces, (I) principles of prevention to reduce recurrence, (j) product selection, (k) effects of the physical and mechanical environment on the pressure ulcer, (l) strategies for management, and (m) mechanisms for accurate documentation and monitoring of pertinent data, including treatment interventions and healing progress (Bergstrom et al., 1994).
Source: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.
According to the NPUAP, it is also important to never reverse stage a wound. Pressure ulcers heal to a progressively more shallow depth; they do not replace lost muscle, subcutaneous fat, or dermis. A Stage IV ulcer cannot become a Stage III, Stage II or Stage I. When a Stage IV ulcer has healed, it should be classified as a healed Stage IV pressure ulcer (NPUAP, 2000). It should be noted that an ulcer should never be staged if uncertainty exists about the stage. Instead, it is recommended that the wound be described. In describing a wound, it is important to refrain from sizing a wound using dime or quarter sizing; the wound should always be measured. Further, wounds not related to pressure, including partial or full thickness skin loss and burns, are never staged.
Superficial skin damage can also occur when adhesive products are used with any pediatric patient (although the chronically ill and critically ill are at an even higher risk). A skin tear or epidermal stripping is a partial thickness wound, involving tissue loss of the epidermis and possibly the dermis (Bryant, 2000). It is the inadvertent removal of these layers by mechanical means, such as tape removal. A skin tear may present as a broad wound, similar to an abrasion or as a narrow tear in the epidermis. It may be dry with little or no drainage, or have moderate drainage, depending on the location and the extent of epidermal involvement. Some skin tears also will have a viable skin flap; the treatment goal should be to avoid dislodging the flap. The flap should be positioned in an area that optimizes its chances of re-adhering to the wound bed. Dressing choice is important; a dressing should be used that will not stick to the area, such as a hydrogel. If the surrounding skin also is fragile, a dressing without an adhesive border should be considered and secured with a gauze roll. In patients where there is good surrounding skin integrity, a transparent film can be used if little or no drainage is present.
Skin tears or epidermal stripping, as well as tension blisters, can easily be avoided by proper skin preparation, choice of tape, and proper application and removal of tape. Stripping can occur when the adhesive bond between tape and skin is greater than between epidermis and dermis. As tape is removed, the epidermis remains attached to the tape, resulting in painful damage. Tension blisters are the result of tightly strapping the tape during application and distention of the skin underneath. Strapping is mistakenly thought to increase adhesion; however, as the tape resists stretching, the epidermis begins to lift, resulting in a blister at the end of the tape.
A key component to the prevention of skin tears/stripping is to recognize fragile, thin, vulnerable skin (Bryant, 2000). Careful and gentle care is important in routine patient care because most skin tears occur during this time. In addition, the current focus of prevention is on the application of products to serve as a barrier. Skin tears resulting from adhesion can be prevented by appropriate application and removal of tape, use of solid wafer skin barriers, thin hydrocolloids, low-adhesion foam dressings or skin sealant under adhesives, use of porous tapes, and avoidance of unnecessary tapes.
Wound Treatment
The key to properly treating a wound is having a basic sense of the wound healing process and understanding the various products available. For example, moist wounds heal faster than dry wounds. It is easier for a wound in a moist environment to granulate and for the cells to migrate across the wound bed. A moist environment also increases the effectiveness of white blood cells in fighting infection and removing cellular debris (Bryant, 2000). However, if a wound is draining heavily, an appropriate dressing should be used to contain the drainage.
Dressings can be categorized into four types: primary, secondary, occlusive, and semi-occlusive. A primary dressing is one that comes directly in contact with the wound bed. A secondary dressing is used to cover a primary dressing when the primary dressing does not protect the wound from contamination. Occlusive dressings cover a wound from the outside environment and keep nearly all moisture vapors at the wound site. And finally, a semi-occlusive dressing allows some oxygen and moisture vapor to evaporate through the dressing. For a sampling of dressings and their characteristics, see Table 2 .
Nursing Implications
According to clinical practice guideline number 15, set forth by the U.S. Department of Health and Human Services (1994), institutions should design, develop, and implement educational programs to address prevention and treatment of pressure ulcers for patients, caregivers, and healthcare providers; these programs should reflect a continuum of care. Adequate involvement of the patient and caregiver, when possible in treatment and prevention strategies, is highly recommended. In the pediatric population, depending on age, it is not always possible to involve the patient; however, the parents should be involved. In particular, in the critical care environment, involving parents and caregivers can provide a sense of involvement in the care of the child, reducing the sense of powerlessness sometimes experienced by parents of critically ill children. Further educational programs should identify those responsible for pressure ulcer treatment, providing a clear description of each person's role in the treatment process.
An educational program should emphasize the need for accurate, consistent, and uniform assessment, and documentation of the extent of tissue damage. The clinical practice guidelines on the treatment of pressure ulcers suggest a comprehensive educational program. Information in a educational program on the treatment of pressure ulcers should include (a) etiology and pathology, (b) risk factors, (c) uniform terminology for stages of tissue damage based on specific classifications, (d) principles of wound healing, (e) principles of nutritional support, (f) individualized programs of skin care, (g) principles of cleansing and infection control, (h) principles of postoperative care, including positioning and support surfaces, (I) principles of prevention to reduce recurrence, (j) product selection, (k) effects of the physical and mechanical environment on the pressure ulcer, (l) strategies for management, and (m) mechanisms for accurate documentation and monitoring of pertinent data, including treatment interventions and healing progress (Bergstrom et al., 1994).
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