Pressure Ulcers

Today we're going to focus on DTI's

DTI's or Deep Tissue Injuries are the bane of nursing existence.  Although they're always categorized at the beginning of the pressure ulcer list, they're frequently not the most minor kind of pressure ulcer.  

A deep tissue injury indicates that the damage has been done at the level of the bone where the tissue well under the surface has been damaged but the surface tissue has NOT been damaged and remains intact.  

The problem is, that we're not entirely sure what causes some people to develop a deep tissue injury versus a stage one pressure ulcer in the same spot, and even worse, we're not sure what causes some peoples deep tissue injuries to "erupt" while other's heal without causing additional damage.  

When examining a patient's skin a deep tissue injury frequently shares the same appearance as a fresh bruise, but fails to begin to show signs of resolution in the next couple of days, which is the quickest way to differentiate between a bruise and a deep tissue injury.  

Deep tissue injuries, like any other pressure ulcer, are likely to appear primarily over the bony prominences, (shoulders, hips, elbows, sits bones, tail bone/sacrum, and heels). 

Because the skin is intact and still doing it's job and keeping the environment stable, there may be no medical (dressing, medicine) treatment ordered for dealing with a deep tissue injury, instead the orders usually consist of close careful monitoring, frequent turning and reposition, potentially a dry dressing if the area attracts too much moisture, and should include nutritional support. 

One of the things that we do know is that regardless of the pressure ulcer poor nutrition not only contributes to the development and progression of pressure ulcers, but that good nutrition supports healing of pressure ulcers and that good nutrition is a team effort.  

Many times in the records the nutritional support recommended by the physician and/or the nutritionist falls short in actual care, and the person then has even more to overcome in healing the pressure ulcer. 

Because deep tissue injuries can be hard to distinguish from bruising, the staff fails to put measures in place quickly once one develops and many times fails to note them.  They can also be very difficult to see in photographs of patients with non- Northern European skin tones, but they still require the same careful consistent management. 

As with most pressure ulcers an ounce of prevention is worth a pound of cure. 

Abbreviations

This week we're going to focus on our first pressure ulcer related abbreviation.  There aren't many abbreviations directly related to pressure ulcers, but this week, the abbreviation is a common one frequently seen with pressure ulcers and the treatment of those ulcers.

This week's abbreviation is

I and D or  I&D

I and D stands for incision and drainage.

This abbreviation is actually the name of a procedure and its a common procedure to help reduce or eliminate sources of infection in a wound or other infected space.  The surgeon literally makes an incision and drains the area.  But like fish 'n chips, and rock 'n roll it generally sounds when spoken like the medical professional is saying I. N. D.

Examples 

Pt. s/p I & D of the R ORIF hip
    The patient has undergone an incision and drainage of the right hip surgical site where they had previously had an open reduction internal fixation. This can happen if the surgical wound is not healing properly and is usually enough to get the wound to heal properly.

Pt to undergo I and D of left buttock pressure ulcer on Thursday.
    Usually a patient undergoes a debridement of the pressure ulcer but from time to time there are pockets of pus that need an I and D to help fix them, and this is what this type of statement is referring to.  Sometimes you see the procedures listed as debridement with I and D if necessary.

Abbreviations

Todays abbreviation describes an experience that nearly all of us have experienced at one point or another in our lives. It becomes more common to experience one half or another of today's abbreviation over the holiday season as we indulge in too much food or drink.

Without further ado:

N/V

N/V stands for nausea and vomiting.

Examples

C/o of N/V for 48 hours, demonstrates signs of dehydration.

CC: N/V per own admission drank 1 handle vodka in last 8 hours.

Pressure Ulcers

Before we can discuss the various stages of pressure ulcers, it is important to know that while everyone is at risk there are a number of populations that are at increased risk for pressure ulcers.

The reason that these particular populations are at increased risk is that they decreased ability to communicate their needs, decreased ability to feel the need to move, or decreased ability to receive assistance in moving. .

By decreased sensation I mean the person cannot feel the sensation that something is wrong or that the person needs to move, and if they cannot move on their own the patients are likely in a setting such as a broken bone where they require assistance but can tell someone they need to move.

Many times they have multiple disease processes and the lack of heath due to the multiple disease processes means that it takes longer for the wounds to heal and the patients are at increased risk for infection in the wound sites, contributing to increased wound time and starting a nasty cycle.

The primary disease processes that I see associated with pressure ulcers are diabetes, arterial disease, dementia, broken bones (both of which I've spoken briefly about), and spinal cord injuries.  Many times spinal cord injury patients can help with their own care, as most spinal cord injury patients at least in their later stages are alert and oriented enough to understand the importance of moving and repositioning regularly, but they may require assistance.  In this nursing staff preforms an important role, and when patients develop pressure ulcers it is important to have nursing staff review the records because many times nursing staff at the home fail to note that they are documenting or not documenting that they are providing care.

Next week we'll focus on the most difficult type of pressure ulcer, the DTI.

Abbreviations

Today's abbreviation is a disease process.  This particular disease process can cause patients to be at higher risk for developing pressure ulcers because it can leave them with decreased mobility and dependent on others for their care, which are two of the primary risks of pressure ulcers.

Todays abbreviation is

CVA

CVA stands for Cerebrovascular Accident, or more commonly known as stroke.  A small stroke may leave no damage but a bad stroke can leave a patient completely bed ridden.

Examples

Pt suffered from a CVA on 12/34/56. Residual left sided weakness noted.

Dx include CVA. 


It is rare to see this in a sentence except for admission notes.  It is more likely to CVA in a list of diagnoses. It is a common reason for admission to a nursing home in someone who was previously living in an unassisted situation, unlike dementia where it is common to see them living in an assisted situation or with an extended family prior to hospitalization.

Pressure Ulcers

Last time I said we would transition from falls to pressure ulcers, and I think this week we'll start with a brief description of what a pressure ulcer is.

Nearly everyone has suffered from a  stage 2 pressure ulcer at some point in their life, but we don't call them that when we're not in the hospital.  We call them blisters.

Pressure ulcers form from a combination of factors, but two of the biggest factors are rubbing and moisture (just like when you get a blister in your shoe).  Pressure ulcers can occur everywhere on the body, but there are a few spots where they are more likely to occur.  Those spots are the hips, buttocks, and heels of the feet. They form in these spots because they're the most difficult to relieve the pressure on, and the most likely to maintain moisture if there is moisture in the environment.

Pressure ulcers when caught in the early stages can be healed without much work, much like the blister on your heel that you keep clean and dry and dressed until it heals. It is important to recognize a pressure ulcer in the early stages and work on healing the ulcer as soon as it is recognized.

There are 6 overall categories for pressure ulcers (not necessarily in order of importance)

1. DTI
2. Stage 1
3. Stage 2
4. Stage 3
5. Stage 4
6. Unstageable.

The first two stages may not be recognized in patients with dark skin as the surface skin isn't open and redness and under skin damage can be difficult to assess. This is why it's important to turn and reposition regularly and prevent skin breakdown from happening.  Over the next few weeks we'll focus on one stage at a time and discuss the importance of each stage and suggested treatments.  As always a good legal nurse consultant can make a world of difference in these cases, as they can provide insight into the specific development of pressure ulcers, and any contribution the patient may have had.

Abbreviations

After a bit of time off for the Thanksgiving holiday- its back to work with another abbreviation for Monday.

This week we'll deal with infection as it's the most serious complication that a person can experience when they're already compromised from another issue.

The test that is done on the source of the infection is our abbreviation today.

C and S or just C/S

The abbreviation is fairly straightforward. It means culture and sensitivity.  This is the lab test to show what bug is growing and how to treat the bug.  It is an important test to run. The test not only determines which bug is causing the problem but how to treat it, which cuts down on the risk of antibiotic resistance in the bug and increases the chance of returning the patient's body to normal.

Examples:

C/S ordered with urinalysis
C and S showed MRSA susceptible to vancomycin.