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The National Pressure Ulcer Advisory Panel has defined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work is the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001.

Pressure Ulcer Definition
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

Pressure Ulcer Stages

Suspected Deep Tissue Injury:

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Stage I:
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Further description:
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk)

Stage II:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Further description:
Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury

Stage III:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Further description:
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV:
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Further description:
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable:
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Further description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

For more information about Pressure Ulcers and Staging and how to become Wound Care Certified, please visit our registration page.

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Unfortunately, not everyone is up to date on the standards of care. Below is a video in which WCEI’s co-founder Donna Sardina RN discusses Standards of Care and an unfortunate case of malpractice and manslaughter in which a host of care givers were arrested, charged and found guilty for negligence.

As Wound Care Certified Nurses, Doctors and Therapists, it is up to us to deliver the Standard of Care to all of our patients. If you are interested in learning today’s Standards of Care regarding Wound Care and would like more information on Wound Care Certification, visit http://www.wcei.net.

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Turning and Repositioning

To most of us in the Health Care industry, nursing in particular, it is obvious that the best ways to heal wounds is to prevent them in the first place. Sometimes however, that is not so obvious to members of the health care team that care for our patients both young and old and in-between. There are many reasons that can be attributed to that ignorance but that is not the reason for this post. That ignorance can be addressed through further education.

Lets discuss prevention of ulcers and wounds. Assessment of our patients needs is one way to initiate preventative measures. I was reading an article and commentary on Catherine Ratliff, Ph.D., from a meeting at the National Pressure Ulcer Advisory Panel in Arlington, VA

She recommended that caregivers assess four factors to determine an individual’s risk for heel pressure ulcers: age older than 70 years, diagnosis of diabetes, decreased mental status, and lack of movement in the legs and feet. Also, consider whether individuals are ambulatory, walk with assistance, or are confined to bed, she said.

Individuals who are at higher risk, or those who already have a heel pressure ulcer, require stricter interventions, she said. Assess the patient and apply moisturizers more often, work hard to get the individual mobile, and perhaps use devices that take pressure off the heels.

You can read the rest of the article here .

What else can we do to assist preventing wounds from developing on our patients? As Wound Care Certified professionals, we can educate the public before and after they become our patients. Writing articles and submitting them to the web via blogs, making videos that speaks to our knowledge about prevention of wounds is an area that we can improve upon. Diabetic screening and education can be another example of how we can possible prevent development of ulcerations. For example we could do more foot examinations as part of a community outreach. All individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions. This examination should include assessment of protective sensation, foot structure and biomechanics, vascular status, and skin integrity. People with one or more high-risk foot conditions should be evaluated more frequently for the development of additional risk factors. People with neuropathy should have a visual inspection of their feet at every visit with a health care professional.

Skin and Wound Manual

A great resource for any Wound Care or Health Care Provider is the Skin and Wound Resource Manual Use the resources that are available to you. Teach the people you care for to take care of themselves before and when they develop wounds. Prevention of the wound prior to it develops is the best way to heal it!

For more information about becoming Wound Care Certified, please visit http://www.wcei.net

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Come brush on on your debridement skills or learn about Maggot Therapy among other modalities.

This year’s Wild On Wounds Seminar will be held at the Paris Hotel right on the Vegas strip!

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Recently, we have been posting some Assessment skills related articles and WCEI co-founder, Donna Sardina RN, uploaded a slide presentation to Test Your Pressure Ulcer Staging Skills.

Go ahead and click on over to see how you do. Warning: The Presentation contains graphic photos

For more information about becoming Wound Care Certified, check out WCEI.net for upcoming class schedules

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