Pressure ulcer staging

Staging pressure injuries/ulcers not only involves determining the amount of tissue damage, but also determining the cause of the injury. Recognizing red flags that indicate the wound is not pressure related takes discerning visualization and palpation.

Aug 24, 2019
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According to the NPUAP guidelines, the wound in the attached photo would be staged as:

a. Stage 1

b. Stage 2

c. Stage 3

d. Suspected deep tissue injury

Answer: B

The NPUAP guidelines define a Stage 2 pressure injury as the following:

Partial-thickness skin loss with exposed dermis. 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) in not visible 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 shear 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).[i]

Stage 2 PUs tend to be shallow, have distinct edges, have little if any drainage, and have no slough.  If there is drainage, it is serous and not sanguineous.  And they are located over a bony prominence.

Of all the pressure injuries/ulcers that occur in any setting, Stage 2’s are probably the hardest to stage.  The loss of epidermis and partial dermis, as compared to full-thickness dermal loss, can present in different ways depending on the anatomical part and the underlying tissues.  Knowing one’s anatomy is imperative in staging all pressure ulcers, but especially in Stage 2’s.  When in doubt, it is always wise to have a second pair of eyes (i.e. an experienced colleague) visualize the wound and confirm the diagnosis.  In addition, there are several other skin abnormalities that can appear similar to Stage 2 PUs, making it imperative for the clinician to dig deep and solve the riddle of why does this patient have wounded skin.  Some of the differences include the following:

  • Moisture associated skin damage tends to be over a larger area with irregular edges and can involve skin over muscle, adipose and other tissues.  MASD will occur in areas exposed to excessive moisture such as the entire perineal area, the buttocks, or around a draining wound.
  • Incontinence associated dermatitis will also be in the perineal area or buttocks, and usually there is a pattern of wet linen under the patient.
  • Intertriginous dermatitis occurs in skin folds, such as the abdomen or gluteal area, of obese patients.  The skin damage is a result of both perspiration moisture and friction that occurs in the fold.
  • Medical adhesive related skin injury is usually partial-thickness as well, but can occur anywhere that the patient has an adhesive dressing that is improperly removed.
  • Traumatic injuries can occur anywhere on the body and the patient or care-giver should be able to report some history of the injury.

Another delineation that may be problematic is the presence of blisters over bony prominences.  If the fluid in the blister is serous or sero-sanguineous, it would be a Stage 2 because the fluid is a result of the inflammatory process that occurs between the epidermis and dermis, indicating it is only partial-thickness.  If, however, the fluid in the blister is sanguineous the diagnosis would be suspected deep tissue injury.  In this case, the blood in the blister is a result of the capillary destruction that has occurred in the deeper tissue.  Other changes that would be noted around the blistered area, in the case of SDTI, include warmth, color changes, bogginess, or coolness.  If the blister is not located over a bony prominence, this is a red flag that the etiology may not be pressure, but rather an under-lying disorder such as bullous pemphigoid, pemphigus, or allergic reaction.

Treatment of Stage 2 pressure ulcers includes pressure redistribution by frequent repositioning or specialty surface (especially cushions for the wheelchair-bound patient), proper fitting of the wheelchair,[ii] adequate nutrition, blood sugar control, and protection of the wound with a dressing that will facilitate re-epithelialization.   Although both silicone-backed foam dressings and hydrocolloids are used to prevent skin injury and to cover Stage 2 PUs, silicone-backed dressings cause less discomfort for the patient during dressing removal than do hydrocolloids.

It is also important to note that as deeper PUs heal and re-epithelialize, they may have an appearance similar to Stage 2 PUs; however, wounds are NOT staged in reverse.  A Stage 3 that is fully granulated and re-epithelializing would be staged that way – a Stage 3 in the proliferative phase; and if fully closed but discolored from scar tissue, a Stage 3 in the remodeling phase.

The subtle innuendos of PU staging are vast and confusing, and even the most experienced clinician can sometimes be baffled by the conundrum!

[1] National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.  Available at www.internationalguideline.com/static/pdfs/NPUAP-EPUAP-PPPIA-CPG-2017.pdf

[1] Sprigle S.  Measure it: Proper wheelchair fit is key to ensuring function while protecting skin integrity.  Advances in Skin & Wound Care.  2014:27(12):561-572.

 

Further information on diagnosing and treating pressure injuries/ulcers may be found at the following site:

 

Garcia AD, Sprigle S. Pressure injuries and ulcers. In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition.  New York: McGraw Hill Education.  2019, 171-198.  Available at https://accessphysiotherapy.mhmedical.com/book.aspx?bookid=1334

 

[i] National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.  Available at www.internationalguideline.com/static/pdfs/NPUAP-EPUAP-PPPIA-CPG-2017.pdf

[ii] Sprigle S.  Measure it: Proper wheelchair fit is key to ensuring function while protecting skin integrity.  Advances in Skin & Wound Care.  2014:27(12):561-572.

 

Further information on diagnosing and treating pressure injuries/ulcers may be found at the following site:

 

Garcia AD, Sprigle S. Pressure injuries and ulcers. In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition.  New York: McGraw Hill Education.  2019, 171-198.  Available at https://accessphysiotherapy.mhmedical.com/book.aspx?bookid=1334

 

According to the NPUAP guidelines, the wound in the attached photo would be staged as:

  • Stage 1
  • Stage 2
  • Stage 3
  • Suspected deep tissue injury

Answer: B

The NPUAP guidelines define a Stage 2 pressure injury as the following:

Partial-thickness skin loss with exposed dermis. 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) in not visible 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 shear 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).[i]

Stage 2 PUs tend to be shallow, have distinct edges, have little if any drainage, and have no slough.  If there is drainage, it is serous and not sanguineous.  And they are located over a bony prominence.

Of all the pressure injuries/ulcers that occur in any setting, Stage 2’s are probably the hardest to stage.  The loss of epidermis and partial dermis, as compared to full-thickness dermal loss, can present in different ways depending on the anatomical part and the underlying tissues.  Knowing one’s anatomy is imperative in staging all pressure ulcers, but especially in Stage 2’s.  When in doubt, it is always wise to have a second pair of eyes (i.e. an experienced colleague) visualize the wound and confirm the diagnosis.  In addition, there are several other skin abnormalities that can appear similar to Stage 2 PUs, making it imperative for the clinician to dig deep and solve the riddle of why does this patient have wounded skin.  Some of the differences include the following:

  • Moisture associated skin damage tends to be over a larger area with irregular edges and can involve skin over muscle, adipose and other tissues.  MASD will occur in areas exposed to excessive moisture such as the entire perineal area, the buttocks, or around a draining wound.
  • Incontinence associated dermatitis will also be in the perineal area or buttocks, and usually there is a pattern of wet linen under the patient.
  • Intertriginous dermatitis occurs in skin folds, such as the abdomen or gluteal area, of obese patients.  The skin damage is a result of both perspiration moisture and friction that occurs in the fold.
  • Medical adhesive related skin injury is usually partial-thickness as well, but can occur anywhere that the patient has an adhesive dressing that is improperly removed.
  • Traumatic injuries can occur anywhere on the body and the patient or care-giver should be able to report some history of the injury.

Another delineation that may be problematic is the presence of blisters over bony prominences.  If the fluid in the blister is serous or sero-sanguineous, it would be a Stage 2 because the fluid is a result of the inflammatory process that occurs between the epidermis and dermis, indicating it is only partial-thickness.  If, however, the fluid in the blister is sanguineous the diagnosis would be suspected deep tissue injury.  In this case, the blood in the blister is a result of the capillary destruction that has occurred in the deeper tissue.  Other changes that would be noted around the blistered area, in the case of SDTI, include warmth, color changes, bogginess, or coolness.  If the blister is not located over a bony prominence, this is a red flag that the etiology may not be pressure, but rather an under-lying disorder such as bullous pemphigoid, pemphigus, or allergic reaction.

Treatment of Stage 2 pressure ulcers includes pressure redistribution by frequent repositioning or specialty surface (especially cushions for the wheelchair-bound patient), proper fitting of the wheelchair,[ii] adequate nutrition, blood sugar control, and protection of the wound with a dressing that will facilitate re-epithelialization.   Although both silicone-backed foam dressings and hydrocolloids are used to prevent skin injury and to cover Stage 2 PUs, silicone-backed dressings cause less discomfort for the patient during dressing removal than do hydrocolloids.

It is also important to note that as deeper PUs heal and re-epithelialize, they may have an appearance similar to Stage 2 PUs; however, wounds are NOT staged in reverse.  A Stage 3 that is fully granulated and re-epithelializing would be staged that way – a Stage 3 in the proliferative phase; and if fully closed but discolored from scar tissue, a Stage 3 in the remodeling phase.

The subtle innuendos of PU staging are vast and confusing, and even the most experienced clinician can sometimes be baffled by the conundrum!

[1] National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.  Available at www.internationalguideline.com/static/pdfs/NPUAP-EPUAP-PPPIA-CPG-2017.pdf

[1] Sprigle S.  Measure it: Proper wheelchair fit is key to ensuring function while protecting skin integrity.  Advances in Skin & Wound Care.  2014:27(12):561-572.

 

Further information on diagnosing and treating pressure injuries/ulcers may be found at the following site:

 

Garcia AD, Sprigle S. Pressure injuries and ulcers. In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition.  New York: McGraw Hill Education.  2019, 171-198.  Available at https://accessphysiotherapy.mhmedical.com/book.aspx?bookid=1334

 

[i] National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.  Available at www.internationalguideline.com/static/pdfs/NPUAP-EPUAP-PPPIA-CPG-2017.pdf

[ii] Sprigle S.  Measure it: Proper wheelchair fit is key to ensuring function while protecting skin integrity.  Advances in Skin & Wound Care.  2014:27(12):561-572.

 

Further information on diagnosing and treating pressure injuries/ulcers may be found at the following site:

 

Garcia AD, Sprigle S. Pressure injuries and ulcers. In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition.  New York: McGraw Hill Education.  2019, 171-198.  Available at https://accessphysiotherapy.mhmedical.com/book.aspx?bookid=1334

 


























Rose Hamm

Physical Therapy, University of Southern California

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