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How Do Pressure Injuries and Wound Affect PDPM?

Presented By:Jeri Lundgren, RN, BSN, PHN, CWS, CWCN, CPT

PresidentSenior Providers Resource, LLC

•PDPM Pressure Injuries and Wounds• Impact under the nursing and non‐therapy ancillary (NTA) components

• Ensure Proper Diagnoses and Assessments of Wounds

• Pressure Injury • Diabetic Ulcers• Arterial • Venous• Other

• Ensure proper staging of pressure ulcers

• Infections: Septicemia, foot infections and/or osteomyelitis 

PT and OT Components

•Utilizing the primary diagnosis and any surgical procedure, the resident will be categorized into one of the four major clinical categories:

•Non‐Orthopedic Surgery Category• Major surgery – repair of deep ulcers (surgical debridement would not count)

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Nursing Component

•Special Care High:•Septicemia is one of them

Nursing Component: Special Care Low•Foot infections•Diabetic foot ulcer

•Prone to arterial insufficiency and peripheral neuropathy – must be diagnosed as Diabetic

•Open lesions on the foot w/ dressing to feet

Nursing Component

Nursing Component: Special Care Low•≥ 2 Stage 2 Pressure Ulcers & ≥ 2 skin treatments

•≥1 stage 3, 4, or unstageable slough/eschar pressure ulcers & ≥ 2 skin treatments

•≥ 2 venous/arterial ulcers & ≥ 2 skin treatments

•1 stage 2 pressure ulcer & 1 venous/arterial ulcer & ≥ 2 skin treatments

Nursing Component

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Nursing Component

•Clinically Complex Qualifiers:•Burns•Surgical wounds or open lesions w/treatment

NTA (non‐therapy ancillary) Component

•Bone/joint Muscle Infections = 2

•Wound Infection = 2

•Other foot skin problems: Diabetic Foot Ulcer code = 1

•Active Diagnosis: Multi‐drug resistant organism = 1

•Special Treatments/Programs: Isolation post‐admit code = 1

NTA (non‐therapy ancillary) Component

•Highest stage of unhealed pressure ulcer : stage 4 = 1

•Other foot skin problems: Foot infection, other open lesion on foot, except diabetic foot ulcer = 1

•Severe Skin Burn or Condition = 1

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The Definition of Pressure Injuries•National Pressure Injury Advisory Panel (NPIAP) Definition April 2016:•A pressure injury is 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. 

Pressure Injuries

Contributing Factors: Shear (deformation of tissue)

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Contributing Factors: Shear (deformation of tissue)

Stage 1 Pressure Injury• Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

• Intact skin with a localized area of non-blanchable erythema (redness), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 1 Appearance

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Deep Tissue Injury• Deep Tissue Pressure Injury (DTPI): Persistent non-

blanchable deep red, maroon or purple discoloration• Intact or non-intact skin with localized area of persistent

non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3, or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Deep Tissue Injury• Internal stresses and strains adjacent to bony prominences are substantially higher than those near the surface, and have the potential to cause damage in deep tissues before the superficial tissue is damaged (NPUAP, 2014, p.20)• Immobility due to hospitalization or surgical procedures• Prolonged ambulance transport• Waiting to be assisted after a debilitating event (fall, CVA, etc.)

Deep Tissue Injury

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Evolution of a Deep Tissue Pressure Injury

Evolution of a Deep Tissue Pressure Injury

Stage 2 Pressure Injury• Stage 2 Pressure Injury: Partial-thickness skin loss

with exposed dermis:Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

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Stage 2 Appearance

Stage 3 Pressure Injury• Stage 3 Pressue Injury: Full-thickness skin loss:

Full-thickness loss of skin in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Stage 3 Pressure Injury

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Stage 4 Pressure Injury• Stage 4 Pressure Injury: Full-thickness skin and tissue loss

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Stage 4 Appearance

NPUAP Position Statement (9-27-12)1

•Although the presence of visible or palpable cartilage at the base of a pressure ulcer was not included in the stage 4 terminology; it is the opinion of the NPUAP that cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage 4.

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Unstageable Pressure Injury• Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.

Unstageable Appearance

Assessment

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Arterial Insufficiency

Arterial Insufficiency

Characteristics of Arterial Insufficiency1:Extremity becomes pale/pallor with elevation and

has dependent rubor

Arterial Insufficiency

Characteristics of Arterial Insufficiency1:Atrophy of skin, subcutaneous tissue and muscleShiny, taut, thin, dry skinHair lossDystrophic nails

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Arterial Insufficiency Characteristics of Arterial Insufficiency1: Increased pain with activity and/or elevation

(intermittent claudication, resting, nocturnal and positional)

Arterial Insufficiency

Characteristics of Arterial Insufficiency1:Purpura

Arterial Insufficiency

Characteristics of Arterial Insufficiency1:Perfusion

• Skin Temperature:-Cold/decreased

• Capillary Refill-Delayed – more than 3 seconds

• Peripheral Pulses- Absent or Diminished

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Arterial Insufficiency Tests

Testing for Arterial Insufficiency1:Ankle Brachial Index (ABI) 

< 0.9 Arterial Insufficiency

< 0.6 to 0.8 Borderline Perfusion< 0.5 Severe Ischemia< 0.4 Critical Ischemia Limb Threatened

Arterial Insufficiency Tests

Testing for Arterial Insufficiency1:Systolic Toe Pressure

TP < 30mmHg

Transcutaneous Oxygen Pressure Measurements (TcPO2)TcPO2 < 30 mm Hg

Arterial Insufficiency Ulcers

Location of Arterial Ulcers1

• Toe tips and/or web spaces• Phalangeal heads • Over lateral malleolus• Areas exposed to pressure or repetitive trauma

(shoe, cast, brace, etc.)• Mid-tibia (shin)

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Arterial Insufficiency Ulcers

Typical Wound Appearance1

“Punched out” appearanceDry, pale or necrotic wound baseMinimal or absent granulation tissueWound size usually small & may be deepMinimal exudateGangrene (wet or dry), necrosis commonLocalized edema (may indicate infection)

Arterial Insufficiency UlcersPossible complications1

Cellulitis Gangrene

Osteomyelitis

Venous Insufficiency

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Venous Insufficiency

Lower Leg characteristics3

-EdemaPitting or non-pitting

Venous Insufficiency

Lower Leg characteristics3

-Venous Dermatitis (erythema, scaling, edema and weeping)

Venous Insufficiency

Lower Leg characteristics3

–Hemosiderin StainingBrown staining (hyperpigmentation)

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Venous Insufficiency

Lower Leg characteristics3

-Active Cellulitis

Venous Insufficiency Characteristics of Venous Insufficiency3

PainMinimal unless infected or desiccated

Peripheral PulsesPresent/palpable

Capillary RefillNormal‐less than 3 seconds

Venous Insufficiency Ulcers

Location of Venous Ulcer3

-Medial aspect of the lower leg and ankle-Superior to medial malleolus

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Venous Insufficiency Ulcers

•Typical Wound Appearance3

-Wound edges: irregular-Wound bed: ruddy red, yellow adherent of loose

slough, granulation tissue, undermining or tunneling are uncommon, wounds are shallow-Amount of exudate: mild, moderate to heavy-Peri-wound skin: macerated, crusty, scaling, hyper-

pigmented

Venous Insufficiency

Peripheral Neuropathy

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Peripheral Neuropathy

Characteristics of Peripheral Neuropathy2

Relief of pain with ambulationParasthesia of extremitiesAltered gaitOrthopedic deformitiesReflexes diminishedAltered sensation (numbness, prickling, tingling,

burning sensation)

Peripheral Neuropathy

Characteristics of Peripheral Neuropathy2

Intolerance to touch (e.g., bed sheets touching legs)Presence of callusesFissures/cracks, especially the heels

Peripheral Neuropathy

Assessing for Peripheral Neuropathy2

Light pressure using a Semmes-Weinstein Monofilament ExamVibratory sense using a tuning forkDeep tendon reflexes of ankle and knee

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Peripheral Neuropathy

Assessing for Peripheral Neuropathy2

Assess for arterial Insufficiency as it commonly co‐exists with peripheral NeuropathyAssess feet for: Reduced skin temperature

Capillary refill of greater than 3 seconds Limb color changes (pallor on elevation and dependent rubor)

Diminished or absence of pedal pulses

Recommend an ABI

Peripheral Neuropathy

Location of Peripheral Neuropathy Ulcers2

Plantar aspect of the footMetatarsal headsHeelsAltered pressure pointsSites of painless trauma and/or repetitive stress

Peripheral Neuropathy

Characteristics of Peripheral Neuropathy Ulcers2

DeepPainlessEven wound marginsCallus surrounding the ulcerGranular tissue unless arterial insufficiency

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Peripheral Neuropathy

Complications of peripheral neuropathy2

CellulitisGangreneOsteomyelitis

Peripheral NeuropathyComplications of peripheral neuropathy2

Charcot fracture Edema

Erythema Increased temperature

X‐ray confirming fractures and dislocations

Diabetic Ulcers

• Diabetics are prone to:•Arterial insufficiency AND/OR•Peripheral Neuropathy

• If they are diabetic and have a foot ulcer secondary to arterial and/or neuropathy, have the primary diagnosis of the wound be a diabetic ulcer 

•Also, then have the secondary diagnosis of arterial insufficiency and/or peripheral neuropathy. 

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• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

• National Pressure Ulcer Advisory Panel (NPUAP). (2007). Updated Pressure Ulcer Stages. Retrieved May 29th, 2014 from http://www.npuap.org

• Wound Ostomy and Continence Nurses Society. (2016). Guideline for Prevention and Management of Pressure Ulcers. Mount Laurel, NJ: Wound, Ostomy, and Continence Nurses Society.

Bibliography 

Thanks for your participation!!!

Jeri Lundgren, RN, BSN, PHN, CWS, CWCN, CPT

President

Senior Providers Resource, LLC

jeri@seniorprovidersresource.com

Cell: 612‐805‐9703

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