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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.