New Definitions of Pressure Wounds

WARNING: Some images might prove upsetting to viewers. 

Pressure ulcers, aka pressure sores or bed sores, normally develop of the bony areas of the body like the heels, hips or cheek bone, ankles, ears, elbows, etc..  These sores are caused by lying down or sitting in the same position for a long time.  If there is pressure on your skin for too long, it can cut off the blood supply to the area. The skin gets weak and can die without enough blood. Pressure ulcers are a serious problem. Bedridden people or those confined for very long periods of time in stationary chairs or in wheel chairs are in danger of developing these sores.

Pressure ulcers can occur even in under the best care conditions and are not necessarily an indication of neglect.  Total prevention of these wounds from occurring has not been proven to be possible.  Nevertheless, because these ‘injuries’ can lead to disfigurement and /or infection, their development on the skin must always be looked for and their presence addressed immediately.

Pressure wound prevention is a top concern of knowledgeable and loving caregivers and professional care staff.  These skin care concerns have been a source of major concern and dread as they can lead to survey citations and even litigation.  It is true that pressure sores are sometimes associated with factors such as neglect, inadequate staffing or poor nutritional care.

Certified Nursing Assistants (CNAs) and Certified Personal Care Aides (PCAs) are critical in skin care and wound detection.  It is important they they have current clinical knowledge, tools, support and ongoing education about this subject.  As  Senior Care Auditors are increasingly used by families as independent care quality assessors to check up on care attendants, attention to the care and management of the skin of those who choose to age at home can be better monitored and more quickly reported, in cases of neglect.


Senior Care Auditing is  one of the few 21st century fast growing career paths.  Find out more about Senior Care Auditing and the Senior Care Auditor career at



In recent years there have been some innovations in wound care prevention and management, but communication and team cooperation (if there is a team) are ideal paths to successful treatment.  NPUAP, the National Pressure Ulcer Advisory Panel, serves as the authoritative voice for improved patient outcomes in pressure injury prevention and treatment through public policy, education and research.  Recently this organization replaced the term “pressure ulcer” with “pressure injury”.  This change is creating quite a stir  It is contended by the group that the change in terminology more accurately describes pressure injuries to both intact and ulcerated skin.

Many practitioners are concerned about the new nomenclature because of issues with lawsuits related to the language.  It is feared that Attorneys might wrongly suggest or conclude that injury implies fault.

New Definitions

What is a pressure injury? 

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 might 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 micro-climate, nutrition, perfusion, comorbidities, and condition of the soft tissue.

STAGE 1 PRESSURE INJURY This is defined as a non-blanchable erythema of intact skin.  Intact skin with a localized area of non-blanchable erythema, which might appear differently in darkly pigmented skin.  Presence of blanchable erythema or changes in sensation, temperature, or firmness might precede visual changes.  Color changes do not include purple or maroon discoloration; these might indicate deep tissue pressure injury.

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STAGE 2 PRESSURE INJURY  Presents as partial-thickness skin loss with exposed dermis.  The wound bed is viable, pink or red, moist, and might also present as an intact or ruptures 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 micro-climate 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, including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (skin tears, burns, abrasions).

STAGE 3 PRESSURE INJURY  Presents as full thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.  Slough and / or eschar might be visible. 

The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.  Undermining and tunneling might 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 4 PRESSURE INJURY  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 might 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 Unstageabe Pressure Injury.

Families and friends use Certified and registered Senior Care Auditors to make sure your loved one is getting the skin care attention they deserve. Become a certified senior care auditor today!

UNSTAGEABLE PRESSURE INJURY  obscured and full thickness skin loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

DEEP TISSUE PRESSURE INJURY (DTPI)  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 deeply 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 might 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, neurpathic, or dematologic conditions.


MEDICAL DEVICE RELATED PRESSURE INJURY  Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes.  The resultant pressure injury generally conforms to the pattern or shape of the device.  The injury should be staged using the staging system.

MUCOSAL MEMBRANE PRESSURE INJURY  This type of injury is found on mucous membranes with a history of medical device in use at the location of the injury.  Due to the anatomy of the tissue, the injuries cannot be staged.

Senior Care Auditing is  one of the few 21st century fast growing career paths.  Find out more about Senior Care Auditing and the Senior Care Auditor career at

Posted in Advocacy, Aging, Aging at home, Alzheimer's Caregiving, Caregiving, Caring for a Veteran, Certified Caregiving, Elder Abuse and Neglect, Elder Care, Elder Law and Finances, Government, News, Nursing Home & Assisted Living, Professional Eldercare, Senior Care Auditing, Uncategorized | Tagged , , , , , | Leave a comment

Required Emergency Preparedness Basic Surveyor Training Course

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CMS’ New Emergency Preparedness Regulation


CMS’ Emergency Preparedness Rule goes into effect November 16, 2017. This will be the first time home health agencies will be required to have an emergency preparedness plan in place. Emergency Preparedness Training: The Centers for Medicare & Medicaid Services.  CMS has developed the new Emergency Preparedness Training which is available on demand and learners may access it at their convenience: 24 hours a day, 7 days a week, and 365 days a year.

The Emergency Preparedness Basic Surveyor Training Course is a required course
for all State Survey Agency (SA) and Regional Office (RO) surveyors and reviewers
who conduct or review health and safety or LSC surveys for emergency preparedness
requirements. Non-survey professionals and other SA or RO support staff responsible for
ensuring compliance with regulations are also encouraged to take the course.

Senior Care Auditing is  one of the few 21st century fast growing career paths.  Get certified now as a Senior Care Auditor and earn 5 certifications for 1 all inclusive low price only at  Find out more about Senior Care Auditing and the Senior Care Auditor career at

All surveyors are required to take the training prior to surveying the Emergency
Preparedness requirements. Surveying for requirements begins November 15th, 2017.
How to Self-Enroll: Learners may self-register and self-launch the course on the Integrated Surveyor Training Website at



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School for Military Caregivers of Veterans

PsychArmor Institute’s School for Military Veteran Caregivers and Families, sponsored by USAA, contains over a dozen free, on-demand, self-paced courses to empower those who care for our Veterans. These courses can help caregivers and families develop skills and knowledge to provide care and support for their Veteran and themselves; learn about the VA, benefits, and how to access services; and better understand the most prevalent health issues Veterans face.

One of their newest courses, Coaching a Loved One Into Care, can help you talk to your Veteran about seeking help.

This is an extensive overview of material that will provide answers and further resources for caregivers of all types.

PsychArmor Institute is a national nonprofit that provides free education and support to all Americans who work with, live with, or care for military veterans and their families. PsychArmor recruits nationally recognized subject matter experts to create and deliver relevant online courses on issues related to veterans and their families.

All caregivers of the elderly or adults with special needs need complete education and certification. Make sure your care provider is educated and certified by

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Home Fitness Business for Aging in Place

In-Home Fitness Solutions clients are offered individualized services based on their fitness goals and current health status, according to Tyler Dukes, who assesses patients and comes up with a plan, often with the inclusion of family members. After seeing skilled nursing facility patients continue to be admitted with conditions that were largely preventable, Tyson Dukes started thinking about starting his own company to help keep seniors at home longer.

“One of the things I kept noticing was, frequently, people would come into the skilled nursing facility for short-term or long-term care, and I thought if I could have seen these people before their fall or accident, I could have helped them and prevented them from a stay in a SNF,” Dukes told Home Health Care News.

With this in mind, Dukes gained a senior fitness specialist certification and set out to help seniors by preventing falls and accidents that could land them in the hospital or a SNF. In July 2017, he officially opened the doors to In-Home Fitness Solutions, which offers at-home fitness health programs for seniors on an individualized basis.

The five core programs offered focus on strength training, balance training, flexibility, coordination training and mobility training. Much of the focus is on helping seniors avoid falls and fractures at home, one of the most common reasons for SNF admission that Dukes observed during his long-term care tenure and the leading cause of injury and death in older Americans, according to the Centers for Disease Control and Prevention (CDC).“I tell all my clients that before we do anything, we have to bring up their foundational strength, like building a home,” he said.

 “You can’t build a home without a good foundation, and older adults unfortunately lose some of that foundational strength over time.”Some clients will do fitness sessions several times per week at home to gain strength and balance before Dukes will focus on maintaining their current level and continuing to build. Maintenance, he says, is a word that doesn’t always bode well with insurance providers in terms of covering costs.Currently, all the services are paid for out of pocket by clients.

Become a Certified Senior Care Auditor and have a great career for the future.  Get started on your senior care auditor certification today at

 Looking ahead, Dukes sees potential for the business to expand rapidly across the state.“I want to grow the business to where it’s not only in my region, but throughout the state of Iowa,” Dukes said. “My expectation is to be a franchise business where we can partner with other good companies to offer services and help people stay at home as long as possible.”Dukes is also currently working on building relationships with home health and home care providers in the area, and other service providers focused on proactively keeping seniors healthy at home.

 Right now, his biggest challenge is educating prospective clients and other regional providers about the services, he said.“At the end of the day, I just want to help people stay at home, where their identity is based,” he said.Tyson Dukes, an Okoboji, Iowa-based physical therapist assistant, has spent the last 20 years working in health care and several years in long-term care.

Edited permission: Havi Vardit

Written by Amy Baxter

Posted in Aging at home, Caregiving, Caring for a Veteran, Elder Care, Elder Care Goods and Services, Holistic Eldercare, News, Senior Natural Health Care, Stories | Tagged , , , , | 1 Comment

Acting as our patients’ / parents’ advocates for home care

There is inherent tension dealing with a policy flawed by its quixotic attempts to distinguish between acute and long-term functional dependencies.

Specifically, they need to learn how to tell when needed services are not available because of Medicare regulations and when they are not available because an agency has a defensive policy that is designed to protect it from aggressive oversight.

Acting as our patients’ advocates for home care can be difficult because practices that meet patients’ needs and serve the public interest can exceed the intent of technical regulations.

Physicians providing care to frail patients who have difficulty leaving home or are not able to manage their own medical care at home should learn about the home health services and home care services that are available in their communities. Make sure all non-licensed care providers are certified and registered at

Several organizations, including the American Academy of Home Care Physicians, can help physicians deal with local home health care agencies. Physicians should identify home health agencies that have practice styles and perspectives that are complementary to their own and then build an interdisciplinary team slowly, patient by patient. Health systems can foster team building with more organizational support.

Why you should consider becoming a Senior Care Auditor

At a policy level, home care services need to be kept under the umbrella of prospective payment, so that the clinical nuances of each patient can be weighed when the consequences of home care are balanced against the consequences of acute hospitalization or long-term institutionalization. This change would prevent cost shifts based upon location of care.

It is our responsibility to take charge of the system and advocate for change that leads to a shared responsibility between physician, home care agency, and patient. Perhaps we should focus on bringing about a system we would want for ourselves, should we ever need it.

R. Miller MD


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What ancient Egyptians believed about Death

Ancient Egyptians believed that upon death they would be asked two questions and their answers would determine whether they could continue their journey in the afterlife.

The first question was, ‘Did you bring joy?’

The second was, ‘Did you find joy?

~Dr. Leo Buscaglia

Learn how to bring joy and excellence to caregiving.  Become an educated and certified informal, professional caregiver, or Senior Care Auditor with

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Two Aging in Place Careers for the 21st Century


As the elderly population numbers rise so has the desire to age in place.  For practical reasons of finances, and personal comfort and freedom, the trend for end of life residence has been to remain at home.  Nursing home numbers have been in steep decline for over a decade and that trend shows no sign of changing.

This new age trend toward permanent residence in one’s own familiar environment does require competent, proactive assistance to unfold as smoothly as possible over time.  Otherwise, either an expensive and/or dreadful assisted living facility is going to be one’s new address.

The older population is increasingly aware of the need for at home care. Their families are, too.  Some relatives step up others simply are not able to for whatever reason.  Both the oldster and the relatives are also aware of the dicey help they are likely to get from their loved one or the average home care agency. After all everyone has heard true stories of the child or care aide from hell, right?

So, if you like to work with frail adults and you need a career with long term possibilities and you do not have thousands of dollars to invest or the desire to get a 2 or 4+ year degree, and you do not want to be at the lowest end of the wage line, what are your options?  Consider these two, both of which open opportunities for you to work for yourself or for an agency in a matter of days or weeks for less money than you might imagine.

Personal care can be safe and enjoyable- if you know how to provide it!

Home Care / Senior Care / Elder Care / Long Term Care Careers for under $200

How to become a CPCA (Certified Personal Care Aide)

Certified Personal Care Aides (CPCA) are the most needed and requested service providers in the at home care industry.  Hundreds of studies of proven that care aides who have been properly educated enjoy their work more, get better quality positions and make more money.

Frail elders need assistance with the ADLs (Activities of Daily Living): cooking, bathing, dressing and grooming, etc.  If you are physically strong and do not mind helping people with their most intimate physical needs, becoming a Certified Personal Care Aide is a good choice.

How do I become a CPCA?  There are only a few Care Aide programs in the country. This online certification program for Personal Care Aides, only available at, is great for both informal family primary caregivers and professional personal care aides (after all, they do the same work).

Here’s why we say this to you…

CertifiedCare offers the only one that is accredited and  comprehensive PCA program that includes Alzheimer’s – Dementia and Special Needs education.  This program is only available online, has 4 modules and requires no other books or materials to complete at your own pace (no deadlines) – Certified Care gives you everything you need to get certified quickly and conveniently all in one package for under $200.

Become a real Certified Senior Care Auditor online at and earn credentials respected around the world.

Home Care / Senior Care / Elder Care / Long Term Care Careers for under $300

How to become a CSCA (Certified Senior Care Auditor)

Harvard Study about Senior Care Auditing

Like oldsters but not so much the personal care work?  Consider becoming a CSCA.  CSCAs check on frail elders who are aging in place and observe their circumstances and general overall condition and make reports.  Typically, the elder, their relative or a loving friend pays for the visit.  At this time, the only way to become an accredited Certified Senior Care Auditor is through the CSCA program at Certified Care (  This program is only available online, has 5 modules and requires no other books or materials to complete – Certified Care gives you everything you need to get certified and registered quickly and conveniently for under $300.

Watch video on Elder Abuse

Believe it or not, caring for an elder is not like caring for a child and the same rules do not apply.  Hurting a frail elder physically or emotionally is very easy to do, and can land you in court or jail whether or not you meant the harm.  Learning how to properly care for a frail senior can be done in person at bricks and mortar schools for lots more money (bricks and mortar are pricey overhead).  Check your local area for that option. Or, if you have a smartphone or access to a computer you can take a full program online, study and test at your own pace, and get certified and registered automatically at for less than $300.

Another good and unique thing about ‘The Org’ is that consumers and agencies check their registry for credentials verification and to find better qualified care aides.

Get affordable, convenient, comprehensive Certified Care Aide and Senior Care Auditing certification at

Did you know that you can go from being a CPCA to being a CSCA easily? This is a good idea from the long term view.  Eventually, most PCAs just do not want the physical demands of ADL care, so they can become SCAs and continue to work with the population they love.

Providing care for those Aging in Place is truly a 21st Century career path with long term life to it. And, the best thing is you do not have to sign up for a lifetime of debt to get into it!

Find out more about Senior Care Auditing here

FAQs about Senior Care Auditing


About Becoming a Personal Care Aide in the USA

By Cathleen V. Carr, JD PhD


Posted in Aging at home, Caregiving Career, Caring for a Veteran, Certified, Certified Caregiver, Certified Caregiving, Elder Care, Elder Care Goods and Services, Professional Eldercare, Senior Care Auditing | Tagged , , , , , , , , , , | 1 Comment