staging of pressure ulcers

Introduction

• pressure ulcers are usually over bony prominences & are graded or staged to classify the degree of tissue damage observed
• staging of pressure ulcers consistent with recommendations of the National Pressure Ulcer Advisory Panel (NPUAP, 1989) as derived from previous staging systems proposed by Shea (1975) & the International Association for Enterostomal Therapy (IAET, 1988) is as follows:

Staging

• Stage 1:
  • nonblanchable erythema of intact skin
  • the heralding lesion of skin ulceration
  • Note: reactive hyperemia can normally be expected to be present for 1/2 to 3/4 as long as the pressure occluded blood flow to the area (Lewis & Grant, 1925); this should not be confused with a Stage 1 pressure ulcer.
• Stage 2:
  • partial thickness skin loss involving epidermis &/or dermis
  • the ulcer is superficial & presents clinically as an abrasion, blister, or shallow crater
• Stage 3:
  • full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, not through, underlying fascia
  • tendons, muscle & bone are not visible
  • the ulcer presents clinically as a deep crater with or without undermining of adjacent tissue
  • a pressure ulcer with depth of 1 cm & minimal nonviable tissue is stage 3
• Stage 4:
  • full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (for example, tendon or joint capsule)
  • exposed tendons, muscle &/or bone
  • Note: undermining & sinus tracts may also be associated with Stage 4 pressure ulcers
• Deep tissue injury
  • painful purpura or blood-filled blister due to damage to underlying soft tissue
  • intact skin
• Unstageable ulcer
  • full thickness ulcers in which the wound bed is obscured by slough, escar or both

All Stage 2, 3, & 4 pressure ulcers are colonized with bacteria

Staging definitions recognize the following limitations:

• assessment of Stage 1 pressure ulcers may be difficult in patients with darkly pigmented skin.
• when eschar is present, accurate staging of the pressure ulcer is not possible until the eschar has sloughed or the wound has been debrided.

Management

• see pressure ulcer