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I Stage, II Stage, III Stage , IV…. Making Pressure Ulcer Staging a Little Easier

Friday, June 6th, 2014

There has to be a way to get everyone on the same page. You would think that over the last 6-7 years since the National Pressure Ulcer Advisory Panel (NPUAP) had released the updated staging guidelines we would have gotten better at this. Not necessarily the case. Pressure Ulcer Staging
Lets try to make pressure ulcer staging as simple as possible. We will take out the all the extra verbiage; you can read that later on. We will break staging down to some user-friendly terms. Now remember, we are talking about pressure ulcers, so all of these skin injuries pressure had to be present, sure – friction and shearing can contribute, but pressure must be present. They are usually located over a bony prominence but we know they don’t have to be; they will be located anywhere the skin has had unrelieved pressure. If they are related to a device they will take on the shape of the device that has caused the injury to the skin.

Pressure Ulcer Staging Made Easy

Stage I

This is an area of non-blanchable area of erythema (redness) of intact skin. That’s what it is. Period. Intact red skin. Non-blanchable is when we push on the skin it stays red; it doesn’t turn white or blanch. So, intact, non-blanchable area of erythema, a stage I pressure ulcer.

Stage II

This is a superficial or shallow open area. We say it is pink, partial and painful. The damage is into the dermis here so the tissue we see will always be smooth pink/dark pink, not granulation tissue. Never will we see any necrotic tissue here; your wound won’t have yellow, black brown colors in it. It also may be an intact serum (clear fluid) blister. So there you have it; a stage II is a superficial open area with NO necrotic tissue or it can be an intact or ruptured serum filled blister.

Stage III

This stage is easy. Damage is now into the subcutaneous tissue, but not through the subcutaneous layer.  So this is the start of full thickness tissue injury.  Now here is where we can start see slough, eschar, and granulation tissue in the wound bed.  Tunneling and undermining may also be present in the full thickness pressure ulcer.  In the stage III pressure ulcer we may see healthy subcutaneous tissue, necrotic tissue or granulation tissue.  What we WON’T see in the stage III is muscle, tendon, ligament or bone, ever.

Stage IV

This is full thickness tissue damage where we now see muscle, tendon, ligament, or bone in the wound bed.  The definition also states “palpable” so if we can feel tendon or bone here, we would stage it as a stage IV.   Cartilage in the wound bed would be included in the stage IV pressure ulcer.  We can have granulation tissue or necrotic tissue present in the wound bed as well.  Undermining and tunneling may be present in a stage IV, but what I MUST see or feel are those underlying structures – muscle, tendon, ligament and / or bone present to say it’s a “stage IV.”

Unstageable Pressure Ulcers

Unstageable pressure ulcer is a stage we use to classify the pressure ulcer that has enough necrotic tissue present to make the clinician uncertain whether the pressure ulcer is a stage III or stage IV.  So until enough necrotic tissue can be removed we place it in the “unstageable” category.  Once that necrotic tissue is removed and we can evaluate the actual level of tissue destruction in the wound bed, that is when we will stage it and it will either be a stage III or a stage IV.

Suspected Deep Tissue Injury (SDTI).  To be a SDTI the skin must be intact, it must be purple or maroon in color or an INTACT BLOOD filled blister.  Once this intact SDTI pressure ulcer opens up, we would then reclassify it based on our assessment or tissue type in the wound bed.

We need to use the staging definitions set out by the National Pressure Ulcer Advisory Panel (NPUAP) correctly, and all clinicians who assess skin need to have a good understanding of these definitions in order to properly stage pressure ulcers.  What was discussed about above is just a summary, there is more reading we need to do, but this will give us a good place to start with the staging.  We need to start staging consistently across the healthcare continuum; it really just comes down to good wound assessment skills, knowing the tissue type that lies before your eyes and identifying the level of tissue destruction and applying them to the NPUAP staging definitions. Lets get this right!

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Trimming Those Tricky Diabetic Toenails

Thursday, March 7th, 2013

diabetic toenails

You are getting ready to trim your diabetic patients toenails. What exactly does that all involve? Well, first you need the proper tools for diabetic toenails. A set of toenail nippers, nail file, and orange stick are typically used. Always follow your facility or healthcare’s settings policy for infection control. Single use disposable equipment is favorable.

You have gathered your equipment to trim the patients diabetic toenails, now what? Nails are easiest to trim after a bath or soak for 10 minutes to soften nails. The soaking of diabetics feet should only be done by a healthcare professional. You can clean under the patients toenail with an orange stick (wearing gloves), wiping on a clean washcloth in between each toe during soaking. .

After soaking and washing of the feet are completed, dry the patients feet completely. Wash your hands and put on gloves to trim the toenails. Use your dominant hand to hold the nipper. Start with the small toe and work your way medial toward the great toe. Squeeze the nipper to make small nips to cut along the curve of the toenail. Be careful not to cut the skin. Use your index finger to block any flying nail fragments. Nippers are used like a pair of scissors – make small cuts, never cut the nail in one clip all the way across the nail. Never use two hands on the nipper. The nail is trimmed in small clips in a systematic manner. The nail should be cut level with the tips of the toes, never cut so short or to break the seal between the nail and the nail bed. The shape of the nail should be cut straight across and an emery board should be used to slightly round the edges. When filing diabetic toenails always use long strokes in one direction, avoid using a back and forth sawing motion.

When all toes have been trimmed and filed, remove your gloves and wash your hands. Apply clean gloves and apply lotion to the top of the foot and to the soles of the feet, rubbing lotion in well, and wipe excess lotion off with a towel. Put the patient’s socks and shoes back on as needed. Wash your hands and smile, you are done!

For your patients who are trimming their own diabetic toenails at home teach them the following simple instructions: Be sure you have good lighting. Trim toenails after bathing, dry feet well, especially in between the toes. Start with the little toe and work your way into the great toe. Use small cuts, never cut the toenail across all at once. Cut straight across and use a nail file to smooth edges. Apply lotion to the bottom and tops of the feet, never in between the toes. For patients with thickened toenails or yellowed toenails, recommend a foot care specialist like a podiatrist cut their toenails.

Posted in Diabetes, Diabetic Wound Management | Comments Off on Trimming Those Tricky Diabetic Toenails