Practice Dilemmas: Conditions That Mimic Pressure Ulcers/Injuries- To Be or Not To Be?

BACKGROUND: Pressure ulcers/injuries (PU/Is) negatively affect patients by causing pain and increasing morbidity and mortality risks. Care teams have a heightened sense of awareness of the condition and may feel confident in their ability to appropriately identify and manage PU/Is, but the potential for, and consequences of, a misdiagnosis always should be considered. PURPOSE: The purpose of this compendium is to describe and illustrate conditions that may mimic PU/Is. METHODS: Advanced practice wound care nurses were asked to identify and describe conditions that may mimic PU/Is. Permission was obtained from all patients to use their cases and photos in this article. RESULTS: Sixteen (16) different skin and wound presentations resulting from vascular diseases, systemic infections, trauma, cancer, autoimmune disorders, coagulopathies, and multisystem organ dysfunction were identified and described. CONCLUSION: A complete patient history and assessment will help prevent misidentification of the etiology of a skin lesion or wound and misdiagnosis of these lesions as PU/Is.

The Origin of Present-on-admission Pressure Ulcers/Injuries Among Patients Admitted from the Community: Results of a Retrospective Study.

Research about community-acquired pressure ulcer/injuries (CAPU/I) remains limited. PURPOSE: The aim of this descriptive, retrospective study was to quantify the number of patients with pressure ulcers/injuries (PU/Is) present on admission (POA), with particular attention to patient residence (home or skilled/long-term care facility [SNF]). METHODS: Data from the electronic medical records (EMR) and the incident reporting system of a 620-bed integrated health system in northern California from January 1, 2017, to December 31, 2017, were examined and used to create a registry that included patient demographics, length of stay (LOS), source of admission (home versus SNF), co-existing conditions, and documentation on end of life and death. A manual chart review was conducted to confirm the accuracy of data entered into the registry. All patients at least 18 years old and with a nurse-reported incident and EMR-documented PU/I that was listed as POA were included; pediatric, pregnant, or incarcerated patients were excluded. Extracted variables included demographic data, stage of PU/I on admission, and major diagnosis (or co-existing condition) by groups (spinal cord injuries [tetraplegia, paraplegia], neurological conditions, end-stage renal disease, cardiac and vascular disease, end of life [EOL], and death while in hospital during the year 2017). Descriptive analysis was used to examine the data. RESULTS: Of the 2340 records of patients with an PU/I POA, 477 were complete and analyzed. The majority (336, 70.4%) originated from home. Patients admitted from home were younger than those admitted from SNF (average age 62.9 and 71.5 years, respectively) and had a higher proportion of co-existing paraplegia/tetraplegia (24.4% vs 12.8%). More than 60% of all patients had a stage 3, stage 4, or unstageable PU/I. CONCLUSION: The majority of patients with a PU/I POA were admitted from home. Additional research and improved efforts to help high-risk individuals living at home prevent and manage PU/Is are needed.

The NPUAP Meeting - This was No Consensus Conference.

The National Pressure Ulcer Advisory Panel (NPUAP) held a Consensus Conference on Pressure Ulcer Staging April 8-9, 2016 in Chicago, Illinois. This was conducted by a moderator and six NPUAP members who were designated as the staging task force. This consisted of 4 nurses, 2 of which were nurse practitioners, one dietician and an individual with a Ph.D. in mechanical and aerospace engineering. Their purpose was "to revise the staging definitions to further clarify and refine the system and develop new nomenclature relevant to pressure related soft tissue injury" (Consensus Conference on Pressure Ulcer Staging, 2016). Many of the changes were not made by consensus but were predetermined by the task force. This includes the following changes. Pressure ulcers are now pressure injuries. The stages are described with Arabic numbers rather than Roman numerals. There are two new pressure categories - medical device related pressure injury and mucosal membrane pressure injury. New artwork has been created to depict the stages. There were changes made to all the stages, but only some of this was by consensus. These revisions were announced by press release on April 13, 2016.

Kennedy terminal ulcer: the "ah-ha!" moment and diagnosis.

The Kennedy Terminal Ulcer (KTU) is an unavoidable skin breakdown or skin failure that occurs as part of the dying process. Research is limited but the literature suggests that KTUs are typically pear-shaped, red/yellow/black, similar in appearance to an abrasion, and tend to occur suddenly in the sacral/coccygeal region not long before death. In this case study, one resident of a long-term care facility suddenly developed a full-thickness ulcer. The ulcer did not respond to treatment and the resident died 6 weeks following ulcer development. Another resident, admitted with a full-thickness ulcer, also did not respond to standard measures of care and general skin failure was observed. She died after 5 months. Research about end-of-life phenomena such as skin failure is needed to help clinicians, caregivers, and patients understand what is occurring and facilitate the provision of optimal and appropriate end-of-life care.