Wound Care Today

WOUND CARE TODAY

2016,Vol 3, No 1

PRESSURE INJURY STAGING AT A GLANCE

›

Staging pressure injuries can

seem challenging...

Despite ongoing controversy and debate around the revised pressure injury staging system

(see

pp. 4–5

), there is a need for staging/classifying to help determine the degree of pressure

damage, with this information being used to help guide management plans and monitor

progress. This piece outlines the recent amendments made by the National Pressure Ulcer

Advisory Panel (NPUAP) to the staging system to help clinicians understand this important,

but challenging, aspect of care.

With identification and prevention

of pressure ulcers being seen as an

indication of the quality of care given

(Vowden andVowden, 2015), and the

requirement to accurately document

all wounds (National Institute for

Health and Care Excellence [NICE],

2014a, b), it is vital that healthcare

professionals keep abreast with new

developments in staging pressure

ulcers — or pressure injuries as

they are now termed. The updated

National Pressure Ulcer Advisory

Panel (NPUAP, 2016; bit.ly/2eC9nCB)

staging system, defines a pressure

injury as:

... localised 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/

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,

comorbidities and condition of the

soft tissue.

The updated system includes the

following stages.

›

Practice point

Pressure injuries have previously

been described as:

›

Bed sores

›

Pressure sores

›

Decubitus ulcers

›

Pressure ulcers.

Some of these terms imply that

only those who are bedbound can

develop them. However, while

poor mobility is a risk factor,

mobile patients can also develop

pressure injuries.

STAGE 1 PRESSURE INJURY:

NON-BLANCHABLE ERYTHEMA

OF INTACT SKIN

This refers to intact skin with a

localised area of non-blanchable

erythema, which may look different

in darkly pigmented skin. Presence

of blanchable erythema or changes in

sensation, temperature, or firmness

may occur before visual changes.

Colour changes do not include

purple or maroon discoloration;

as these may indicate deep tissue

pressure injury.

STAGE 2 PRESSURE INJURY:

PARTIAL-THICKNESS SKIN LOSS

WITH EXPOSED DERMIS

This refers to 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) 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 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).

STAGE 3 PRESSURE INJURY:

FULL-THICKNESS SKIN LOSS

This refers to full-thickness loss of

skin, in which adipose tissue is visible

in the ulcer and granulation tissue

and rolled wound edges are often

present. Slough and/or eschar may be

visible. The depth of tissue damage

varies according to the anatomical

location; areas of significant

adiposity can develop deep wounds.

Undermining and tunnelling may

also occur. Fascia, muscle, tendon,

ligament, cartilage and/or bone are

not exposed. If slough or eschar hides

the extent of tissue loss, this is an

unstageable pressure injury.

STAGE 4 PRESSURE INJURY:

FULL-THICKNESS SKIN AND

TISSUE LOSS

This refers to 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. Rolled edges, undermining

and/or tunneling are often present,

with the depth varying according

to anatomical location. If slough or

eschar hide the extent of tissue loss,

this is again an unstageable

pressure injury.

›

Key changes

›

Pressure injury replaces

pressure ulcer

›

Arabic numbers used instead

of roman ones

›

Two new ‘additional’

definitions added.