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Staging: New Guidelines

for Pressure Ulcers

Kristie Hartig BSN, RN, PHN, WCC, SWOC

(Injuries!)

OBJECTIVES

�Learners will be able to more effectively identify and stage pressure injuries

�Attendees will be able to

describe changes to the staging system

Annually, there are an estimated

1 million to 3 million patients with

pressure injuries in the United States.

“Pressure ulcers cost $9.1-$11.6 billion per year in the US. Cost of individual patient care ranges from $20,900 to $151,700 per pressure ulcer.”

SOURCE: AHRQ: 1. Are We Ready for This Change?: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. April

2011. Agency for Healthcare Research and Quality, Rockville, MD.

Pressure Injury

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Pressure Injuries are not

� Arterial Ulcers

� Neuropathic Ulcers

� Diabetic Ulcers

� Venous Ulcers

� Abscesses

� Skin Tears

� Surgical Wounds

WHAT IS THE BEST

TREATMENT FOR A

PRESSURE INJURY?

Pressure Injury

PREVENTION!

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What causes aPressure Injury?

Pressure Injury

Pressure

Pressure is a perpendicular force

exerted on a localized area of tissue

Shear

Shear exerts force parallel to the skin as gravity

pushes down on the body against a resistant surface

Friction

Friction occurs when skin rubs against another

surface

Pressure Injury

Pressure Injuries can form over areas of

bony prominence, from prolonged immobility.

Pressure Injury

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Pressure Injury

Where do you look?

Pressure Injury

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Patient

on

side

Patient

on back

Patient in a wheelchairPatient higher than 30°

Pressure Injury

Where else

can we look?

Pressure Injury

• Under tubing

• Foley catheters

• Feeding tubes

• Oxygen tubes

Pressure Injury

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• Under medical devices

• Splints

• Braces

• Restraints

• Diapers

• Heel protector straps

• Compression stockings

Pressure Injury

Medical Device Related Pressure Injury:

This describes an etiology

Medical device related pressure injuries result

from the use of devices designed and applied

for diagnostic or therapeutic purposes. The

resultant pressure injury generally conforms to

the pattern or shape of the device. The injury

should be staged using the staging system.

Pressure Injury

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Pressure Injury

Mucosal Membrane Pressure Injury

Mucosal membrane pressure injury is

found on mucous membranes with a

history of a medical device in use at the

location of the injury. Due to the anatomy

of the tissue these ulcers cannot be staged.

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National Pressure Ulcer Advisory Panel (NPUAP)

A pressure injury is localized damage to the skin and 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/or 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, co-

morbidities and condition of the soft tissue.

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Pressure Injury

Identifying

Pressure

Injuries

Healthy Skin

Redness

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Pressure Injury Staging

Pressure Injury

Stage 1

Pressure Injury

Stage 1 Pressure Injury:

Non-blanchable erythema of intact skin

Intact skin with a localized area of non-blanchable erythema, which may appear

differently in darkly pigmented skin.

Presence of blanchable erythema or changes in sensation, temperature, or firmness

may precede visual changes.

Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

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Stage 1 Pressure Injury: Non-blanchableerythema of intact skin

Stage 1 Pressure Injury: Non-blanchableerythema of intact skin

Stage 1 Pressure Injury

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Stage 1 Treatment

• Offload area• Apply protective skin barrier• May use dressings such as:

Transparent dressingGranulexProdermXenaderm

• Monitor for changes

Stage 2

Pressure Injury

Stage 2 Pressure Injury:

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) is 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).

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Pressure Injury

Stage 2 Pressure Injury

Stage 2 Treatment

• Offload area• Apply protective skin barrier to periwound• If open use dressings such as:

HydrogelHydrocolloidTransparent dressing

• Monitor for changes

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Stage 3

Pressure Injury

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Stage 3 Pressure Injury:

Full-thickness skin loss

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar

may be visible.

The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep

wounds.

Undermining and tunneling may occur.

Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or

eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Stage 3 Pressure Injury

Stage 3 Treatment

• Offload area• Apply protective skin barrier to periwound• If no slough use:

Collagen based productHydrogelHydrocolloid – used to be the practice

• If slough is present, use Santyl• Monitor for changes

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Stage 4

Pressure Injury

Stage 4 Pressure Injury:

Full-thickness skin and tissue loss

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. Epibole (rolled edges), undermining

and/or tunneling often occur.

Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is

an Unstageable Pressure Injury.

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Stage 4 Pressure Injury

Stage 4 Pressure Injury

Stage 4 Treatment

• Offload area• Apply protective skin barrier to periwound• If no slough use:

Collagen based productHydrogel

• If slough is present, use Santyl• Monitor for changes

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Unstageable

Pressure Injury

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.

Full-thickness skin and tissue loss in which the extent of tissue damage within

the ulcer cannot be confirmed because it is obscured by slough or eschar.

If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.

Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic

limb should not be softened or removed.

Unstageable Pressure Injury:

Obscured full-thickness skin and tissue loss

Pressure Injury

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Pressure Injury

Unstageable Pressure Injury

Unstageable Treatment

• Offload area• Apply protective skin barrier to periwound• If dry and intact (as in over the heel) keep clean,

dry, and protect from traumatic removal• If fluctuant necrosis, or dry necrosis, can

debride chemically or sharp debride• If slough is present, use Santyl – score eschar

first• Monitor for changes

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Deep Tissue Pressure Injury

(This is a Stage 4 pressure ulcer, until proven otherwise)

Pressure Injury

Intact or non-intact skin with localized area of persistent non-blanchabledeep red, maroon, purple discoloration or epidermal separation

revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes.

Discoloration may appear differently in darkly pigmented skin.

This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to

reveal the actual extent of tissue injury, or may resolve without tissue loss.

If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates

a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic,

neuropathic, or dermatologic conditions.

Pressure Injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure and/or shear.

(This is a Stage 4 pressure ulcer, until proven otherwise)

Pressure Injury

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Deep Tissue Pressure Injury

26%

35%

39%

Initial Description of DTI

Group 1 (Purple,

Bruised, Red, Boggy,Stage I)

Group 2 (Stage II,Blistered)

Group 3 (Black,Necrotic, Unstageable)

Deep Tissue Pressure Injury

DTI In Obese Male Post Gastric Banding

Fatal DTPI Due to Placement on Bedpan

Bedpan edge evident

Deep Tissue Pressure Injury

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• Offload area• No debridement is called for until the wound has

declared itself• May use dressings such as:

Clear Barrier OintmentVenelexFoam dressing

• Monitor for changes• If fluctuant necrosis, or dry necrosis, can debride

chemically or sharp debride• Monitor for changes

Deep Tissue Pressure Injury

Interventions

Pressure Injury

Interventions based on the subscales of the

Braden Scale Pressure Ulcer Risk Assessment

• Sensory• Moisture• Activity• Mobility• Nutrition• Friction & Sheer

Pressure Injury

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� Turn patient at least every 2 hours, more frequently as needed

� Offer fluids/hydration

� Offload (heels, sacrum)

� Protect the tissue (barrier cream, ointment, or paste)

� Moisturize the skin (lotion)

� Offer BSC, toilet, or urinal

� Monitor Nutritional intake

Pressure Injury

Turning the

patient

� Head of bed no more than 30°

� Lateral turn no more than 30°

Pressure Injury

Specialty SurfacesPowered Air Mattresses

Pressure Injury

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NOTES:

* you do still need to offload heels from an air mattress surface

* be careful not to elevate legs when offloading arterial disease

patients

Offloading pressure from the heels

vs. protectingthem from

friction

Pressure Injury

Protect the

tissues

� Cleaning your patient provides excellent protection

� Shower/bathe patient

� Don’t forget to wash your

patient’s hands!

� Moisturize the skin

� Use protective skin barriers

Pressure Injury

� Use dimethicone, petrolatum, zinc oxide or copolymer barriers for buttocks

and diaper areas

� Don’t forget to protect high risk friction areas (heels / elbows)

Pressure Injury

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Resources

Thanks to NPUAP (an organization focused on improving pressure ulcer prevention and treatment through education, research and public policy) for making information in this presentation possible. www.npuap.org

Resources

Additional

information can

also be found at

the Agency for

Healthcare

Research and

Quality.

www.ahcpr.gov