The Importance of Documentation in Pressure Injuries

Excelas had the opportunity to attend a webinar given by Jeri Lundgren, President of Senior Providers Resource, on assessment and staging of pressure injuries.  Ms. Lundgren shared her expertise concerning the types of pressure injuries, etiology, contributing factors, assessments and staging, and the importance of documentation.  Her expertise and experience in wound management and care provided for a highly educational presentation.

The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.  The injury can present as intact skin or an open ulcer and may be painful.  The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.  The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue.  The injuries can be further classified as medical device related or mucosal membrane pressure injury.

The cause of the injury is ischemia from sustained deformation of soft tissues which leads to hypoxia, blocking of nutrient supply and removal of waste products.  The duration of time that tissue cells can endure ischemia differs between muscle, fat, and skin.  The microclimate, or humidity and temperature between the skin and supporting surface, plays a role in causing the skin to become weaker and less stiff.

The most common sites of pressure injuries include the ischium, lateral ankle bones, heel, and sacrum.  Shear, including force and rolling effect, contribute to the deformation of tissue.  Of note, moisture associated skin damage (MASD) secondary to incontinence or perspiration is not a pressure injury.

Assessment of the wound is essential to determine progress and appropriate interventions and should be documented at least every seven days.  More frequent documentation should occur with any complications or dressing changes.  Ms. Lundgren stressed wound assessment should be a team effort.

A comprehensive assessment of a wound includes date, location, stage, size and depth, wound base description, undermining and tunneling, drainage, wound edges, odor, signs and symptoms of infection, and pain.  The wound bed should be described as necrotic/eschar, slough, granulation and/or epithelial with percentage of the wound bed for each description.

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The staging system for pressure injuries consists of four stages and unstageable.  This system is used for consistent communication of the depth of tissue destruction.

  • Stage 1 pressure injury is non-blanchable erythema of intact skin. Changes in sensation, temperature or firmness may precede visual changes.
    • A deep tissue pressure injury is persistent non-blanchable deep red, maroon, or purple discoloration. Skin may be intact or non-intact.  The DTPI results from intense and/or prolonged pressure and shear forces at the bone-muscle interface and are often due to immobility during hospitalizations or post-surgery, prolonged ambulance transports or waiting for assistance after a debilitating event.
  • Stage 2 pressure injury is partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may be an intact or ruptured serum-filled blister.  Fat and deeper tissues are not visible.
  • Stage 3 pressure injury is full-thickness skin loss in which adipose is visible and granulation tissue is often present. The depth of the damage varies by anatomical location.
  • Stage 4 pressure injury is full-thickness skin and tissue loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.
  • Unstageable pressure injury is obscured full-thickness skin and tissue loss. If slough or eschar can be removed, Stage 3 or Stage 4 will be revealed.

Ms. Lundgren provided guidance on medical record documentation of each aspect of the wound assessment and staging.  She stressed the importance of documenting appropriate goals in the care plan, the type and location of the ulcer, and any history of a pressure injury including the location.  In claims and litigation citing the development of pressure injuries, Excelas’ medical analysts can review the medical records and create a Medical Chronology and/or Case Summary that will provide the entire story regarding the development and treatment of wounds.

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