Wound care: What's new on an old problem?
Jean Wendland Porter
In April, the National Pressure Ulcer Advisory Panel (NPUAP) issued guidance on the terminology and rating of pressure injuries. As a recently-certified Wound Care professional, I found the new terminology arrived just in time.
Does your patient have a pressure sore? A pressure ulcer? A decubitus? No. Your patient has a “pressure injury."
That's a better term for the range of problems with which your patient presents. Calling the involved area an injury more accurately describes what you're seeing. Whether the skin is intact or whether it's open, both are injuries caused by non-distributed, non-alleviated pressure.
In the previous staging system, Stage 1 and DTI (Deep Tissue Injury) both described intact skin, not an “ulcer." Furthermore, the term “suspected” when referring to a DTI is gone too. You'll notice I used the Arabic number 1 instead of the Roman numeral I. That's new too. Pressure injuries have a long and extensive history of being graded and staged using the Braden system (there are others, but that's what most of us use.) The staging system is used to indicate the extent of the injury and those definitions have also been updated. Stage 1, Stage 2, Stage 3 and Stage 4 definitions are unchanged, except that they're not using Roman numerals anymore.
So what's new? Here are new definitions for pressure injuries that haven't been used before:
Medical Device-Related Pressure Injury: Medical device-related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposed. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.
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 injuries cannot be staged. Questions to ask:
- Were the TED hose too tight?
- Did they create a line at the top of skin breakdown?
- Was the patient lying on the Foley tube? (That might also create a linear pressure injury that would qualify under the new definition.)
- Did the endotracheal tube cause an ulcer inside your patient's mouth?
- What about the tracheal cuff?
- Did that cause pressure on the mucous membrane? That would be a non-stageable mucosal pressure injury.
You may be asking why a physical therapist is interested and certified in wound treatment and how your rehab department can be involved. Though nursing is primarily associated with wound care, a physical therapist can debride, clean, and use electrical stimulation on wounds that are not progressing after 30 days. We can also bill for wound care under the patient's insurance.
My practice has recently begun the process of pressure-mapping patients to determine the optimum seating and sleeping surface to prevent wounds before they start, which is also a billable service.
For example, what if your patient shows some red areas on her bottom? Typically, you'd try another cushion, another chair, another mattress and then play the wait-and-see game.
With pressure mapping, we know immediately and objectively whether the cushion we're trying is the right cushion. We can also see whether the mattress is the right one. The technology has given us the objective and immediate ability to see what will keep that patient from sustaining a pressure injury.
As we know, there are always changes that impact just about everything we do. We are nothing if not adaptable. These changes and interventions that are now implemented are just another step in our growth toward better and more efficient processes to benefit our patients and residents.
Jean Wendland Porter, PT, CCI, is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.