When it comes to staging pressure injuries (PI) and identifying moisture-associated skin damage (MASD) it can be challenging. Both types of wounds have similar presentation and show up consistently on the same parts of the body.
Pressure Injury Basics
Pressure injuries (PI) result when prolonged pressure impairs blood flow to an area by compressing tissues/vessels. These injuries are found over bony prominences in the body such as the coccyx, sacrum, scapula, and heels. Medical devices or other foreign objects that put pressure against the body can also cause a pressure-related injury. Common culprits for medical device-related pressure injuries are nasal cannulas, gastric tubes, and indwelling catheters. Other factors such as moisture and nutrition also play a big part in the formation and treatment of pressure-related wounds.
Stage I: Skin is still intact with non-blanchable redness or erythema. The area may be painful, soft, warmer or cooler than the rest of the body.
Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red and/or pink wound bed. The wound bed is without slough. It may also present as intact or open serum-filled blister.
Stage III: Full thickness tissue loss in which subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present, but the visible slough does not obscure depth. May include undermining and tunneling at this stage.
Stage IV: Full thickness tissue loss with exposed bone, tendon, and/or muscle. Slough or eschar may be present on some parts but not enough to cover the wound bed. This stage often has undermining and/or tunneling.
Deep Tissue Injury: Purple or maroon localized area of discolored intact skin. Could also be seen as a blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. Ultimately the skin is still intact, and the depth is unknown at this point in time.
Unstageable: There is full thickness tissue loss in which the base of the ulcer is covered by at least 50% slough and/or eschar. Most of the wound bed cannot be seen and therefore cannot yet be staged.
Moisture Associated Skin Damage Basics
MASD develops when the top layer of skin is damaged first. Top-down skin injury (outer layers of skin are damaged first): The inflammation and erosion of the skin is caused by prolonged exposure to moisture. The sources of moisture may include urine or stool perspiration, wound exudate, mucus, or saliva. The moist and often macerated skin is in a weakened state that is easily damaged by friction. MASD is common between skin folds, around stomas and peri-wounds, and to the peri-region in incontinent patients.
MASD and PIs can be easily confused with one another. It is common for MASD to contribute to the formation of a pressure injury since the tissue has become compromised. A pressure injury with a lot of drainage can also lead to MASD to the peri-wound. While it may be hard to decipher between the two types of skin injuries, here is a quick reference to refer to during an assessment that can help a nurse decide.
Moisture Associated Skin Damage
Cause, Prevent, Treatment: Too much moisture has compromised the skin and led to breakdown. Find a way to control the source of moisture that is damaging the tissues.
Location: Diffusely distributed over an area. Wound margins are often irregular.
Color: Pink or red but is still blanchable.
Depth: Partial thickness tissue loss. Blisters with serous fluid might be present.
Necrosis: None.
Pain: Pain is common. The patient may also complain of burning or itching.
Pressure Injuries
Cause: Pressure is the cause, and the priority is to offload the area or to remove the source of pressure.
Location: Usually over a bony prominence or from a medical device. Wound edges are well circumscribed.
Color: Wound bed may be red, blue, or purple. The wound bed could also be obscured by slough or eschar which would be yellow, white, tan, brown, or black.
Depth: Partial or full thickness depth. Blisters may be present over pressure areas or from equipment or devices. Blisters could be filled with either serous fluid or blood.
Necrosis: May potentially have slough or eschar.
Pain: May or may not be present. Some wounds may not have much feeling if the wound is too deep, and the nerve endings are damaged.
Hospital Acquired Pressure Injuries (HAPIs) – long a major healthcare problem for hospitalized patients – have the potential to increase with the increasing amount of patients requiring ICU care due to COVID-19. Regardless of primary diagnosis, when immobility, pressure, friction, shear, poor nutrition, and poor profusion plague the hospitalized patient, HAPIs often occur. Each year, more than 2.5 million patients suffer from these injuries, costingthe U.S. healthcare system anywhere from $9.1 – 11.6 billion annually.
A pressure injury can manifest itself in many ways, starting from red or purple skin discoloration to more extreme cases where tissue loss can occur. In fact, these injuries which are the second most common lawsuit claim “after wrongful death and greater than falls or emotional distress,” claim the lives of about 60,000 people each year2. Bed surface technology can play a critical role in reducing pressure injuries or their severity.
The onset of COVID-19 has exacerbated the conditions from which HAPIs develop, as many COVID-19 patients require ICU care. Because of severe respiratory problems requiring intubation and ventilators, as well as other equipment used in treatment, injuries can result from an ”intense and/ or prolonged pressure” against a surface or device. More than 30% of all hospital-acquired pressure injuries are the resultof pressure placed on the skinfrom a medical device. In addition to the risk posed by medical devices, the need for patients to be placed in a prone position for long periods of time to help expand the lungs and increase oxygenation, could potentially lead to pressure injuries on parts of the body not usually seen like the faceand other soft tissue locations.
Immobility, Length of Stay Exacerbates Risk of Skin Problems Among Covid-19 Patients
In addition to the problems associated with immobility and increased length of stay, COVID-19 causes its own skin problems. In fact, the National Pressure Injury Advisory Panel (NPIAP), saysthat“the virus itself creates a systemic coagulopathy including hypercoagulation and microvascular occlusion.” Resulting skin changes “appear purpuric and quickly become necrotic.6 The NPIAP goes on to note that these skin changes “mimic” DTPIs (Deep Tissue Pressure Injuries), especially when they occur over tissue exposed to pressure and/or shear forces (e.g., sacrum, buttocks, heels) or under medical devices.” Since DTPIs and COVID-19 skin changes appear to have similar characteristics, it is important that wound care experts involved in the care of these patients have assessment skills that can help differentiate between HAPI and COVID-19 Coagulopathy.
In 2008, the Center for Medicare and Medicaid Services (CMS) stopped reimbursement to hospitals for additional costs related to HAPIs7. If hospitals incorrectly code COVID-19 related skin changes as DTPIs, they will inadvertently penalize themselves. Besides issues of reimbursement, the ability to prevent and treat skin breakdown regardless of the source is critical to hospitalized patients.
The Role of A Well-Designed Support Surface
Part of the prevention and treatment picture for patients at risk for or already experiencing significant and debilitating skin issues includes the appropriate choice of support surfaces on which to place fragile patients. There is an abundance of options available with varying pressure redistribution and microclimate management mediums and making the right choice can seem like a complicated decision.
Amongst the panoply of support surface options, there exist some types that are designed for both treatment and prevention of a wide range of pressure injuries. These support surfaces have much to offer in terms of simplifying the support surface decision for clinicians at the bedside. Great examples of these are support surfaces that utilize technologies like gel and air to redistribute pressure- or constant low pressure (CLP) surfaces. CLP is a desirable option because it can be used for a wide variety of patients of varying acuities and medical situations. From a microclimate standpoint, many support surfaces have Low Air Loss (LAL) technology built right into the surface (such as Stryker’s Isolibrium) and others offer the ease of attaching a pump for use only when indicated on a per patient basis (such as IsoTour). In either situation, using a high quality CLP support surface with optional or built in microclimate management can help dramatically simplify the support surface decision chain within a healthcare facility, while ensuring an appropriate level of protection and treatment for a large portion of the patient population.
It is no secret that the treatment and prevention of pressure injuries encompass so much more than simply selecting the right support surface for a patient, but that understanding should not diminish the clinical impact that an appropriately placed support surface can have on patient outcomes. It is one piece of a complex puzzle, but the puzzle is nonetheless incomplete without all of its pieces.
The vaccines are here, but COVID-19 may still be with us for a long time to come. Critically ill coronavirus patients will face several life-threatening issues up to and including organ failure. Being the largest organ of the body, skin can fail as well. While the pandemic brings new challenges with respect to wound care, bed technology can provide tools that provide support in the prevention of pressure injuries.
Pressure ulcers—commonly known as bedsores—have been a healthcare challenge for millennia, and researchers continue to seek ways to prevent and treat them. One “rising star” in the study of pressure ulcers is DonnaLee Pollack, RN, MSN, MPH, FNP-C, CWCN-AP, who works as a Family Nurse Practitioner in the Wound Clinic at Olin E. Teague Veterans’ Medical Center in Temple, Texas. Pollack is also working on her PhD at the University of Texas at Arlington College of Health and Nursing Innovation and is a 2018-2020 Jonas-Smith Trust Veterans Healthcare Scholar.
In this interview with DailyNurse, Pollack explains . . . Click here to read the rest of this article.
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