Lynn Smith, 74 years, had a total hip replacement. Her suture line was closed with plain interrupted sutures. The postoperative orders indicate removal of sutures in seven days.
Lynn develodecubitus ulcer on her left hip.
The ulcer has a black spot in the middle with sloughy yellow tissue surrounding it and an offensive green exudate.ps a Here you go:
STAGE I
This stage is characterized by a surface reddening of the skin. The skin is unbroken and the wound is superficial. This would be a light sunburn or a first degree burn as well as a beginning Decubitus ulcer. The burn heals spontaneously or the Decubitus ulcer quickly fades when pressure is relieved on the area.
The key factors to consider in a Stage I wound is what was the cause of the wound and how to alleviate pressure on the area to prevent it from worsening. Improved nutritional status of the individual should also be considered early to prevent wound worsening. The presence of a Stage I wound is an indication or early warning of a problem and a signal to take preventive action.
Treatment consists of turning or alleviating pressure in some form or avoiding more exposure to the cause of the injury as well as covering, protecting, and cushioning the area. Soft protective pads and cushions are often used for this purpose. An increase in vitamin C, proteins, and fluids is recommended. Increased nutrition is part of prevention.
STAGE II
This stage is characterized by a blister either broken or unbroken. A partial layer of the skin is now injured. Involvement is no longer superficial.
The goal of care is to cover, protect, and clean the area. Coverings designed to insulate and absorb as well as protect are used. There is a wide variety of items for this purpose.
Skin lotions or emollients are used to hydrate surrounding tissues and prevent the wound form worsening. Additional padding and protective substances to decrease the pressure on the area are important. Close attention to prevention, protection, nutrition, and hydration is important also. With quick attention, a stage II wound can heal very rapidly.
A wound can appear to be a Stage I wound upon initial evaluation, and actually be reevaluated as a Stage II wound during the course of care. Quick attention to a Stage I Decubitus ulcer or pressure wound will prevent the development of a Stage III Decubitus ulcer or pressure wound. Generally Decubitus ulcers or pressure wounds developing beyond Stage II is from lack of aggressive intervention when first noted as a Stage I. [see notation].
STAGE III
The wound extends through all of the layers of the skin. It is a primary site for a serious infection to occur.
The goals and treatments of alleviating pressure and covering and protecting the wound still apply as well as an increased emphasis on nutrition and hydration.
Medical care is necessary to promote healing and to treat and prevent infection. This type of wound will progress very rapidly if left unattended. Infection is of grave concern.
STAGE IV
A Stage IV wound extends through the skin and involves underlying muscle, tendons and bone. The diameter of the wound is not as important as the depth. This is very serious and can produce a life threatening infection, especially if not aggressively treated. All of the goals of protecting, cleaning and alleviation of pressure on the area still apply. Nutrition and hydration is now critical. Without adequate nutrition, this wound will not heal.
Anyone with a Stage IV wound requires medical care by someone skilled in wound care. Surgical removal of the necrotic or decayed tissue is often used on wounds of larger diameter. A skilled wound care physician, physical therapist or nurse can sometimes successfully treat a smaller diameter wound without the necessity of surgery. Surgery is the usual course of treatment. Amputation may be necessary is some situations.
STAGE V
This is an older classification and not now used in all areas. A stage 5 wound is a wound that is extremely deep, having gone through the muscle layers and now involves underlying organs and bone. It is difficult to heal. Surgical removal of the necrotic or decayed tissue is the usual treatment. Amputation may be necessary is some situations.
Notation
It is possible for a wound to "go from a stage I wound to a stage III or IV" without the intermittent stage[s] being observed. All wound stages were present just not obvious, hence the need to treat all wounds as serious with the potential of rapidly worsening. Pressure ulcers are areas of necrosis and ulceration where tissues are compressed between bony prominences and hard surfaces; they may also develop from friction and shearing forces. Risk factors include old age, impaired circulation, immobilization, malnourishment, and incontinence. Severity ranges from skin erythema to full-thickness skin loss with extensive soft-tissue necrosis. Diagnosis is clinical. Treatment includes pressure reduction, avoidance of friction and shearing forces, local care, and sometimes skin grafts or myocutaneous flaps. Prognosis is excellent for early-stage ulcers; neglected and late-stage ulcers pose risk of serious infection and nutritional stress and are difficult to heal.
Classification
The definitions of the four pressure ulcer stages are revised periodically by the National Pressure Ulcer Advisory Panel (NPUAP) in the United States. Briefly, however, they are as follows:
* Stage I is the most superficial, indicated by redness that does not subside after pressure is relieved. This stage is visually similar to reactive hyperemia (a technical term for excessive redness) seen in skin after prolonged application of pressure. Stage I pressure ulcers can be distinguished from reactive hyperemia in two ways: a) reactive hyperemia resolves itself within 3/4 of the time pressure was applied, and b) reactive hyperemia blanches when pressure is applied, whereas a Stage I pressure ulcer does not. The skin may be hotter or cooler than normal, have an odd texture, or perhaps be painful to the patient. Although easy to identify on a light-skinned patient, ulcers on darker-skinned individuals may show up as shades of purple or blue in comparison to lighter skin tones.
* Stage II is damage to the epidermis extending into, but no deeper than, the dermis. In this stage, the ulcer may be referred to as a blister or abrasion.
* Stage III involves the full thickness of the skin, extending into, but not through, the subcutaneous tissue layer. This layer has a relatively poor blood supply and can be difficult to heal. At this stage, there may be undermining damage that makes the wound much larger than it may seem on the surface.
* Stage IV is the deepest, extending into the muscle, tendon or even bone.
* Unstageable pressure ulcers are covered with dead cells, or eschar and wound exudate, so the depth cannot be determined.
With higher stages, healing time is prolonged. While about 75% of Stage II ulcers heal within eight weeks, only 62% of Stage IV pressure ulcers ever heal, and only 52% heal within one year.[1] It is important to note that pressure ulcers do not regress in stage as they heal. A pressure ulcer that is becoming shallower with healing is described in terms of its original deepest depth (e.g., healing Stage II pressure ulcer). |
