Pressure Ulcers

This is where things get tricky.  If they weren't tricky before, they get tricky now.  Stage 1 and two pressure ulcers are only at the surface of the skin.

Stage III pressure ulcers are the first pressure ulcer that does not involve intact skin that involves more than damage to the skin surface.  The difference between a stage III and a stage IV ulcer is the not the size (the total area of the ulcer) but the depth of the ulcer.  A stage 3 ulcer involves the fat that lies below the skin, and there is some debate as to whether or not it involves the musculature, but it absolutely does NOT involve bone exposure or that the clinician can feel the bone through the tissue. (sometimes called palpable).

Once you get away from the surface ulcers (stage 1 and stage II) size NO LONGER MATTERS.

Let me repeat that SIZE NO LONGER MATTERS. 

I'll say it one more time SIZE NO LONGER MATTERS.

I'm pretty sure I cannot emphasize this point enough, because its hard to wrap your head around.  The idea that a stage 3 pressure ulcer that is the size of your entire back is actually not worse than a stage 4 pressure ulcer the size of a pencil that goes all the way to the bone on your leg. This is because the one on across your back looks worse than the one on your leg. In truth the one on the back is NOT worse than the one on the leg.

I'll get into the multitude of problems that a stage IV pressure ulcer can cause next week, because that's not our focus, our focus is the stage III ulcer.

Stage III ulcers like stage I ulcers tend not to last terribly long if they're not caught and treated almost immediately.  Its not long before a stage III ulcer without treatment develops into a stage 4 ulcer.

Depending on the depth, treatment usually involves keeping the wound bed moist and clean to promote healthy tissue generation, and the surrounding tissues dry to prevent additional breakdown, and regular turning and repositioning of the client. If the client's nutritional status has not been previously evaluated, it is CRITICAL to get their nutritional status evaluated and start nutritional support if it's needed. This is because the body puts it's energy into healing these wounds, and it has been my finding, as it has been many others, that patients without adequate nutritional support not only take longer to heal but also are at significantly increased risks for developing additional pressure ulcers and infections.

Pressure ulcers are a slippery slope and once started down them if a stop is not put in place immediately it can lead to death.

For all pressure ulcer cases it is important to have at least one nurse evaluate the case, because the first line of prevention is the nurse providing day to day care.  A wound nurse is ONLY called in once a wound has formed. 

Abbreviations

So we've touched briefly on the abbreviations surrounding today's abbreviation, but I thought we'd focus on the abbreviation for the disease process itself.

SCI- Spinal Cord Injury

This is a general very broad abbreviation that includes everyone from those paralyzed from the upper neck down, to those whom outwardly appear to have no spinal cord damage.  It literally means what it says, that someone suffered damage to their spinal cord. 

The causes of spinal cord injury can be as simple as a bad fall, or as complex as spina bifida or tumor formation.  Usually after an injury there is a huge learning curve for a patient who has suffered a spinal cord injury, in terms of damage done to the spine, and what the prognosis is, but those who can figure out how to live with their injury usually have some of the most positive attitudes that I have seen, and as a nurse I find them a joy to work with. 

Examples

Pt suffered a C5-6 SCI. 

(It is common to see the level of injury (e.g. C5-6) mentioned with the injury as it can have critical impact on the type of care the patient is likely to need. We will explore this more as part of our disease process exploration.)
    
Dx: Incomplete SCI. Pt. is expected to make a full recovery with few deficits. 

(Again- we'll explore exactly what this means at a later date.)  

Abbreviations

This week, we're going to focus on another abbreviation that most people are familiar with because I hear it regularly discussed when people have children, especially small babies.

The abbreviation is

BM-- bowel movement

Nurses are always concerned about whether or not our patients have had one because it is a signal of good health.  A blocked bowel can cause problems, as can too loose flowing a bowel.  Good nursing practice is to know if your patient has had a bowel movement on your shift, or if they have had one on the previous shift.

Although it is normal to go one or two days without a bowel movement it is not common to go longer without one, so this particular item gets its own spot in the output area of a patient's record.  Loose bowel movements can lead to problems including, but not limited, infection in patients that have pressure ulcers in their sacral area, and even their hips.

Example

Pt. had BM, soft formed this shift.

Pt. failed to have a BM this shift, abdomen remains soft and non-distended, bowel sounds present.

Stage II Pressure Ulcers

Stage II pressure ulcers are the most common pressure ulcers that we experience.  Everyone at some point in their life has had an injury similar to a stage II pressure ulcer although we may not have called it that.

Stage II pressure ulcers can be blisters.  The same blisters that we have on our heels or toes when our shoes rub, or we get on our hands after doing unusual yard work without wearing appropriate protection. Stage II ulcers are defined as damage to the outermost layer of the skin.  They sometimes appear as open areas that do not involve the deeper layers of skin, muscle, or bone, and other times as the above described blisters.

That's how stage II pressure ulcers form more often than not, from a combination of moisture and rubbing. A patient left in a wet bed a little too long might form a stage II pressure ulcer.

The best part about a stage II ulcer, is like stage I ulcers they require very little treatment to cure them. The stage II pressure ulcer requires a dry surface and some sort of a protective covering to keep excess moisture out. Many times, ensuring the bed and the area around the wound remains clean and free of excess moisture, either from a dry dressing or a barrier product of some sort, is enough to heal the wound.

This wound is easy to spot on all skin types because unlike the stage I and DTI the skin is clearly broken and no longer intact. In fact because of the lack of intact skin for the first time we have an ulcer that can usually be seen more clearly on a patient with non Caucasian skin tones than those with Caucasian skin tones.

The fact that stage II pressure ulcers are easy to heal makes them difficult from a litigation standpoint.  Many times the wounds heal and don't get any worse without any assistance and the same level of care as prior to the wound, or with the simple expedient of more frequent diaper or bed changes, or ensuring the skin is drier than it was previously. If a stage II ulcer is left untreated though, or if the patient is continually left in a damp situation stage II pressure ulcers can quickly decline into stage III or stage IV ulcer. Each ulcer requires a more complex treatment plan, and even more therapy and costs everyone more.  Many times facilities get into trouble because they fail to reassess their patient's needs at the stage II level.

I am going to spend a few lines here discussing nomenclature. Nomenclature (how you express yourself in writing) for pressure ulcers consists of two different choices.  The common/preferred choice for pressure ulcers is to write their stages as Roman Numerals, however I have seen the ulcers, particularly stage 1 and stage 3 expressed as arabic numerals.  There isn't anything wrong with this and its not uncommon, nor is a deviation for the standard of care, and in writing it can be easier to see stage 3 ulcers specifically when written in arabic numerals. I see them interchangeably used all the time and for the purposes of this blog I will attempt to stick with the roman numerals for expression.

Abbreviations

This week we're going to focus on an abbreviation that comes up frequently in a specific population.  This particular abbreviation can be triggered by a pressure ulcer.

Eventually I'd like to come back and focus more on this abbreviation as part of our disease process exploration because it is a potentially deadly abbreviation.

This week's abbreviation is

AD -  Autonomic Dysreflexia

AD or Autonomic Dysreflexia is a condition that occurs only in patients with spinal cord injuries, when their autonomic nervous system responds to a stimulus inappropriately.  It represents a medical emergency.

The reason I decided to pick this particular abbreviation this week, is the impetus for a stage II pressure ulcer, the focus of our Tuesday post, can cause an AD episode in spinal cord injury patients. Because of the decreased ability to shift their own position, and the deceased ability to feel the need to move, spinal cord injury patients are at higher risk for pressure ulcers.

Examples

Pt is at increased risk for AD due to difficulty of catheter insertion.

Pt.'s AD episode was triggered by wrinkled linen under him.  Stimulus removed and AD episode resolved.

Pressure Ulcers

The next classification is also the easiest to miss completely in pressure ulcers, regardless of skin color.  This is is the Stage 1 Ulcer.  This is because stage 1 ulcers are reddened skin.

Like with all pressure ulcers they're most common on the bony prominence or where your body has increased and regular contact with other surfaces without moving.

The difference between a stage 1 pressure ulcer and reddened skin is its behavior.  Reddened skin when blanched (turned to white by external pressure) immediately shows return of blood (redness to the area).  A stage 1 pressure ulcer will remain white.

Treatment of the stage 1 ulcer is remarkably similar to the deep tissue injury.  This is because the skin is still intact.

The big difference between a stage 1 ulcer and a deep tissue injury is that the injury experienced in a stage 1 ulcer is at the skin rather than at the bone and advancing outwards, therefore not only is more known but it is proven that early nutritional support, regular turning and repositioning, and good cleansing of the skin can heal a stage 1 ulcer before it degrades into something else.

Again like the deep tissue injury these can be next to impossible to spot on non- Northern European skin, and unlike deep tissue injuries these can be mistaken for redness and still manage to successfully heal without any intervention so the staff fails to recognize them as ulcers.

There's not a lot to say on stage 1 ulcers that is not the same as DTI's. Close monitoring is necessary regular turning and repositioning is necessary, but it is very common for stage 1 ulcers to be under reported and under diagnosed.

I like to compare things to the real world and experiences outside of medicine to help make medicine come alive, but this doesn't really have a real world relationship the way that next week's ulcer- the stage 2 does, so stay tuned for me.

Abbreviations

Since we've all just survived the new year, and that for many people involves a lot of drinking I thought we'd focus not so much on an abbreviation but a term that's used when there are patients who have drunk too much in the hospital. 

Banana Bag

As you can see this is not an abbreviation at all but is likely something you would see in a medical record anyway.  This is the fluid that is given to a patient to rehydrate them after they have had too much to drink.  The bag typically contains thiamin, folic acid, and magnesium sulfate and is a distinct yellow color from where it takes its name.  It contains the nutrients that are most depleted when one drinks too much. 

Example:

Pt. received two banana bags. 

Banana Bag hung before patient transferred up to the floor. 

As a note it is uncommon to see the word banana bag in the orders as physician usually order a bag of normal saline containing the amounts of thiamin, folic acid, and magnesium sulfate that the physician wants the patient to receive.  However it is common both in speech and in the progress notes to write banana bag rather than specify the exact amounts of ingredients mixed into the fluids.