Wound Care Today

8 / 36

8 WOUND CARE TODAY 2016,Vol 3, No 1
PRESSURE INJURY STAGING AT A GLANCE i
UNSTAGEABLE PRESSURE
INJURY: OBSCURED FULL-
THICKNESS SKIN AND
TISSUE LOSS
This refers to full-thickness skin
and tissue loss. The extent of tissue
damage within the ulcer cannot be
confirmed as it is obscured by slough
or eschar. If slough or eschar is
removed, a stage 3 or 4 pressure injury
will be visible. Stable eschar (i.e. dry,
adherent, intact without erythema) on
the heel or ischaemic limb should not
be softened or removed.
DEEP TISSUE PRESSURE
INJURY (DTPI): PERSISTENT
NON-BLANCHABLE DEEP
RED, MAROON OR PURPLE
DISCOLORATION
This refers to intact or non-
intact skin with localised areas of
persistent non-blanchable deep
red, maroon, purple discoloration
or epidermal separation revealing
a dark wound bed or blood-filled
blister. Changes in pain and
temperature often occur before
any changes in the skin colour.
Discoloration may appear differently
in darkly pigmented skin.
This type of injury results from
intense and/or prolonged pressure
and shear forces at the bone-muscle
interface. The wound may develop
rapidly to reveal the actual extent
of tissue injury, or may resolve
without tissue loss. If necrotic,
subcutaneous, or granulation
tissue, or fascia, muscle or other
underlying structures are visible,
this indicates a full-thickness
pressure injury (unstageable, stage
3 or stage 4). The staging system
stresses that DTPI should not
be used to describe vascular,
traumatic, neuropathic, or
dermatologic conditions.
ADDITIONAL DEFINITIONS
The revised staging system also has
the following additional pressure
injury definitions.
Medical device-related
pressure injury
Medical device-related pressure
injuries result from using devices for
diagnostic or therapeutic purposes.
The pressure injury that occurs
generally conforms to the pattern or
shape of the device, and should be
staged using the staging system.
The development of a pressure ulcer has a cost impact on NHS
organisations and may have a significant effect on a patient’s quality
of life. Pressure ulcer staging is a challenge in clinical practice;
with evidence indicating that it may be inaccurate in up to 18% of
patients (All Wales Tissue Viability Nurse Forum [AWVTN] and
Welsh Wound Innovation Centre [WWIC], 2016). To ensure accurate
pressure ulcer staging in clinical practice, it is essential that healthcare
professionals have an in-depth understanding of a recognised pressure
ulcer classification, which they can apply effectively when assessing
a patient. This ensures consistency in documentation, guides clinical
decision-making and drives appropriate treatment options.
However, prevention is better than cure, so identifying patients at risk and putting interventions in
place that may prevent pressure damage should be a priority for any clinician.
Kirsty Mahoney, clinical nurse specialist, wound healing, Cardiff and Vale University Health Board
expert opinion
Mucosal membrane
pressure injury
Mucosal membrane pressure
injuries are found on mucous
membranes where medical devices
have frequently been used at the
site of the injury. The staging system
states that these injuries cannot be
staged due to the anatomy of
the tissue.
REFERENCES
AWTVN Forum, WWIC (2016) National
Pressure Ulcer Audit 2015. Unpublished
data presented at the TissueViability
Society Conference, Cardiff
NICE (2014a) Pressure ulcers: the
prevention and mangement of pressure
ulcers. NICE, London. Available
online:
cg179?unlid=799546122016914675
NICE (2014b) Costing statment; pressure
ulcers. Implementing the NICE guidelines
on pressure ulcers (CG 179). NICE,
London. Available online: .
org.uk/guidance/cg179/resources/
costing-statement-248688109
Vowden K,Vowden P (2015)
Documentation in pressure ulcer
prevention and management. Wounds
UK 11(3 Suppl 2): 6–9
WCT