From the category archives:

Pressure Ulcers

Distinguishing Perineal Dermatitis from a Pressure Ulcer

by lswezey on October 1, 2008

Can you tell the difference between perineal dermatitis and a pressure ulcer? Distinguishing between the two conditions can be tricky!

Perineal Dermatitis
Perineal dermatitis can be defined as moisture-associated skin damage and is often the result of urine or fecal incontinence (or both). Patients who wear incontinence pads or briefs may be at higher risk for the condition, as these garments hold moisture against the skin, increasing surface temperature and humidity. These conditions can lead to maceration of the skin.

Perineal dermatitis may show itself as an area of redness on the skin. You may also see scaling of the skin. Papule and vesicle formation may take place. Weeping vesicles may contribute to skin damage. Keeping patients clean and dry is the key to prevention of this condition.

Irritant-Associated Dermatitis
This type of dermatitis is thought to be caused by the skin’s prolonged contact with urine and/or stool, which may result in the release of inflammatory cytokines. Signs and symptoms include:

  • redness, which may spread to skin folds of the buttocks and inner thighs
  • edema
  • blistering
  • skin erosion
  • weeping
  • itching and/or pain in the area

Allergic Contact Dermatitis
This condition may be caused by residue from laundry detergent in patients who wear washable incontinence products. It can also occur from contact with an allergen from a cream or ointment applied to the skin. It may appear rather quickly and spread rapidly. Skin will have a similar appearance to that of irritant-associated dermatitis; however, the key to treating this type of dermatitis is to discover the cause and remove the causative agent.

  • Treating perineal dermatitis includes treating incontinence and protecting the skin from further irritation. Frequent cleansing of the skin with mild soap and water and applying a barrier cream to protect the skin from moisture are sound treatments which should improve the patient’s skin quickly and effectively. If the area becomes infected with yeast or bacteria, use of an appropriate antifungal or antibiotic will be necessary.

Pressure Ulcers
A pressure ulcer is a localized area of injury to the skin, usually over a bony prominence, as a result of pressure by itself or in combination with friction or shear. Stage I or II ulcers can form in the same areas as perineal dermatitis, making an accurate diagnosis difficult. Stage I pressure ulcers usually involve an area of nonblanchable redness over a bony prominence. The skin is intact in Stage I ulcers. Stage II ulcers present as a shallow open area in which the wound bed is pink or red. There is no slough. Alternately, stage II ulcers may present as intact or open serum-filled blisters. In pressure ulcers, pressure and not moisture is the defining element.

Care of the patient with a pressure ulcer involves employing methods to relieve pressure and allow healing of the ulcer by:

  • using pressure-reducing beds, chairs, and other equipment
  • providing optimal nutrition for wound healing
  • turning and frequent repositioning to relieve pressure
  • treating pain

Of course, both of these conditions can occur together. Patients who develop perineal dermatitis are at higher risk of developing a pressure ulcer to the same area, as the skin is already compromised. Prevention of both of the conditions is key to management, and instituting appropriate and rapid treatment once one of these conditions is recognized will produce the best patient outcome.

At woundeducators.com, we are committed to providing you with quality, up-to-date information which will allow you to care for your patients utilizing the best available information. Obtaining wound care certification will allow you to quickly identify and treat any condition that our patients may present with, and will ensure they receive the best treatment possible. Contact us today to find out how you can begin your journey to becoming certified as a wound care specialist.

Interesting Article:  Perineal skin care for the incontinent patient

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Deep Tissue Injury (DTI)

by lswezey on September 24, 2008

Myth # 5-An area of discolored intact skin is most likely a Stage 1 pressure ulcer or a bruise

A deep tissue injury (DTI) is commonly mistaken for a stage 1 pressure ulcer or a bruise. This is a serious error and can have a profound impact on patient outcomes, liability, and reimbursement. 

 

What is a deep tissue injury (DTI)?
Deeper, full-thickness damage to underlying tissue which may appear as purple areas or dark necrotic tissue should not be confused with Stage 1 pressure ulcers.

 

The National Pressure Ulcer Advisory Panel (NPUAP) has defined wounds such as these as “A pressure-related injury to subcutaneous tissue under intact skin. Initially, these lesions have the appearance of a deep bruise”(NPUAP, 2002). DTI’s require rapid identification, as they may quickly progress to Stage 3 and 4 pressure ulcers despite aggressive and optimal treatment.

 

How do DTI’s form?
Fleck (2007) explains that DTI’s form over areas of bony prominence and occur from the inside out. Superficial damage is not seen until later, when tissue undergoes necrosis, reaching the outer layer of skin and resulting in the formation of an external wound. She further stresses that DTI’s can be differentiated from Stage 1 ulcers by their rapid deterioration despite proper care.

 

What are the legal implications of DTI’s?
DTI’s that are not recognized for what they are can have legal implications due to their ability to deteriorate despite stringent wound management practices. They result in increased costs and hospitalization, not to mention pain and suffering for the patient who develops one of these wounds, putting the health care practitioner and the facility at risk for litigation.

 

Salcido (2008) discusses the current Medicare changes that are scheduled to take effect October 1, 2008. These changes will have a huge impact on how hospitals are reimbursed. In regards to wound care, pressure ulcers will be considered hospital acquired (and therefore not reimbursed) unless these wounds are documented within 48 hours of admission. The onus is now on us, as healthcare professionals, to ensure that these wounds never develop, and if they do, they should be well documented and aggressively treated. This new policy is forcing us to examine our wound care management practices.

 

Documentation of DTI’s
Wounds that are suspected as being a DTI should be afforded a full description and the word “DTI” should be mentioned. For those practitioners who work in long-term care with the Minimum Data Set (MDS) documentation system, the word “unstageable” should be used to describe those wounds that are suspicious for DTI. Thorough and ongoing documentation is crucial in respect to DTI’s, as their rapid deterioration may make these wounds particularly tempting targets for litigation.

 

Education is the key to recognition and management of DTI’s
Understanding the etiology of DTI’s and learning how to differentiate these wounds from bruises, hematomas, and other closed wounds that may have a similar appearance is the key to prevention and treatment of these wounds, which have the potential for significant morbidity for patients, as well as being potentially litigious.

 

Woundeducators.com strives to provide you, the healthcare professional, with the information you need to recognize and treat DTI’s and other wounds. Our online wound care certification course can give you the tools you need to protect your patient, yourself, and your agency. If you are interested in becoming wound care certified contact us today, and you can be on your way to an exciting new career.

 

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Are you ready for October 2008?

by lswezey on September 18, 2008

Pressure ulcers have long been an issue for patients immobilized for lengthy periods of time. Although in recent years there has been a greater emphasis and awareness regarding prevention of pressure ulcers, starting in October health care professionals will be held financially responsible for patients who develop pressure ulcers.

What are “never events”?

Never events can be defined as events that should not occur, or preventable adverse events. Along with a long laundry list of circumstances and events such as performing the wrong surgery and blood incompatibility errors, pressure ulcers that develop in patients during the course of their hospital stay will no longer be reimbursed, as set forth in the CMS (Centers for Medicare and Medicaid Services).

Why are pressure ulcers being classified as “never events”?

Pressure ulcers are increasing in hospitalized patients, and patients hospitalized specifically for treatment of pressure ulcers have a higher than average length of stay. Pressure ulcers can lead to extended lengths of stay, infection, pain, loss of function, and even death. As well, the cost of treating pressure ulcers is approximately $11 billion per year.

What does the new ruling mean for healthcare professionals and their employers?

Essentially, the CMS ruling means that if a patient is admitted to the hospital without a pressure ulcer, and subsequently develops a pressure ulcer, the hospital will not be paid for that patient’s care.

What effect will this new ruling have on hospitals, long-term care, and home health care?

Obviously, hospitals that have a high incidence rate of development of pressure ulcers will stand to lose a great deal of money; this could greatly impact the financial viability and well-being of the hospital and, by extension, the hospital staff. Considering that the cost of treating a pressure ulcer can be as much as $70,000.00, the need to take steps to prevent pressure ulcers aggressively needs to start now. Facilities that have a program in place to identify and treat patients at risk for the development of pressure ulcers will fare better than those who don’t.

There are some facilities that are exempt from the CMS ruling. These include critical access hospitals, long-term care hospitals, Maryland waiver hospitals, hospitals that treat only cancer, and children’s inpatient hospitals.

You may be wondering how home care will fare under this new ruling. The implications are ominous for home health care practitioners and their employers. There is no provision under the new CMS ruling that states that pressure ulcers must be healed before patients leave the hospital. This means that home care will then bear the financial responsibility for pressure wounds in patients discharged home with pressure ulcers. Additionally, a difficulty that has been identified in the home care setting is the issue of the healthcare provider’s inability to control the patient and the patient’s family in terms of compliance with wound care prevention and treatment recommendations. This is very important in terms of performance monitoring and risk management.

What can healthcare professionals do to ensure they are prepared to meet the challenges of the new guidelines?

Prevention, accurate assessment, and documentation of wounds will become even more crucial as of October of 2008.
The IHI (Institute for Healthcare Improvement) recommends six steps in the prevention of pressure ulcers:

  • Assess the skin of all patients upon admission for existing ulcers, and identify those at risk of developing ulcers (i.e. Braden scale)
  • Reassess the entire skin daily, observing for development of pressure ulcers or worsening of pre-existing ulcers
  • Assess the patient’s risk factors for pressure ulcers daily
  • Manage moisture properly
  • Optimize the patient’s  nutrition and hydration status
  • Minimize pressure and use pressure minimizing tools properly

In order to meet the new challenges set forth by the new CMS ruling on pressure ulcers, healthcare professionals and agencies must aggressively plan and implement ways to prevent pressure ulcers from occurring. One of the most effective ways to manage this is to ensure that all professionals who deal with at-risk patients are trained in the most current evidence based knowledge available. Woundeducators.com can help to accomplish this goal by providing up-to-date information and training in wound care management and wound care certification. Protect yourself and your facility by engaging in online wound management today, and be prepared for tomorrow.

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