Most Severe Pressure Ulcer

Intent:

To record the highest stage of pressure ulcers on any part of the body present in the last 3 days.

 

Definitions:

Pressure Ulcer - Any lesion caused by unrelieved pressure.  Pressure ulcers usually occur over bony prominences and are staged to classify the degree of tissue damage observed.

Any area of persistent skin redness - An area of skin that appears continually reddened and does not disappear when pressure is relieved.  There is no break in the skin.  Also known as Stage 1.

Partial loss of skin layers - A partial thickness loss of skin that presents clinically as an abrasion, blister, or shallow crater.  Also known as Stage 2.

Deep craters in the skin - A full thickness of skin is lost exposing the subcutaneous tissues.  Presents as a deep crater with or without undermining of adjacent tissue.  Also known as Stage 3.

Breaks in skin exposing muscle or bone - A full thickness of skin and subcutaneous tissue is lost exposing muscle or bone.  Also known as Stage 4.

 

Process:

Consult with the person and family about the presence of an ulcer. If an ulcer exists, the assessor may have to observe the ulcer to determine its stage.

 

Ask if the person has been examined for the presence of pressure ulcers or other skin conditions.  It could be difficult to examine the person’s entire skin, as you are a guest in the person’s home.  For people who are cognitively intact, you can get good information about their skin condition without conducting a skin examination.  For a chair-bound or bedfast person, conduct a skin examination, paying particular attention to the person’s hips, thighs, buttocks, low back and heels.

 

It is sometimes difficult to determine the presence of a reddened area (i.e., a Stage 1 ulcer) in persons with darker skin tones.  To recognize Stage 1 ulcers look for:  (1) any change in the feel of the tissue in a high-risk area; (2) any change in the appearance of the skin in high-risk areas, such as an “orange-peel” look or a subtle purplish hue; and (3) extremely dry crust-like areas that, upon closer examination, are found to cover a tissue break.

 

Coding:

Code the appropriate response in the box to the right of the item.