Frequently Asked Questions About Pressure Ulcer Staging - Wound Care Advisor (2023)

Van Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Assessing the severity of pressure ulcers can be difficult. Below are some frequently asked questions – and answers – about staging.

Q.If the pressure ulcer heals (fully epithelized) but later reopens in the same place, how should it be staged?

W.According to the National Pressure Ulcer Advisory Panel, if the pressure ulcer reopens in the same location, the previous stage pressure ulcer should be replaced
diagnosis (for example, if it was stage IV before closure, it would be stage IV after reopening).1
Remember that bedsores heal slowly. They do not replace lost muscle, subcutaneous fat or dermis until they re-epithelize. Instead, the wound is full-thickness filled with scar tissue composed primarily of endothelial cells, fibroblasts, collagen, and extracellular matrix. A pressure ulcer grade IV can therefore not become a pressure ulcer grade III, grade II or later grade I.1

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Q. Can pressure ulcer staging be used for venous ulcers?

W.NO. The National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel state that the pressure ulcer classification system cannot be used to describe tissue loss in wounds other than pressure ulcers.2

Question If the wound initially looks like a suspected deep tissue injury (SDTI) and then opens, should I record it as SDTI healing or resume treatment as it appears?

W.Stage is based on the deepest level of tissue destruction through the skin layers; therefore you stage according to the level of destruction you see and/or feel. So when a wound changes character, you should repair it based on what you see.
Be sure to refer to the definition for each stage, and if you don't see what you're looking at, document the wound as unstaged.

Q. Once the pressure ulcer is cleaned, does it become a surgical wound and no longer need to be staged?

W.According to the Centers for Medicare & Medicaid Services (CMS), a pressure ulcer that has been surgically cleaned remains a pressure ulcer and is not considered a surgical wound.3,4

(Video) Pressure Ulcer Prevention Learning Session

Q. What would be the new stage of a stage II pressure ulcer where necrosis develops?

W.Since staging is based on the deepest level of tissue destruction through the skin layers, the wound should be graded based on the level of destruction you can see and/or feel.
If a grade II wound is so necrotic that the deepest level of tissue destruction cannot be seen or palpated, it is considered non-serious. However, if there is scattered, superficial debris and the deepest level of tissue destruction can be seen or felt, the wound will be stage III or IV.

Question If a grade IV pressure ulcer is repaired with a surgical flap, is it still grade IV or is it not staged?

W.According to the CMS, if a muscle flap, skin slide flap, or rotational flap is performed to surgically replace a pressure ulcer, that area is considered a surgical wound and is no longer a pressure ulcer. If the flap fails, continue
code the area as a surgical wound until it heals.3,4

Q. Can an ulcer have two stages? My patient has a grade 3 pressure ulcer, but I also see dark purple around parts of it. Should I document it as stage III with suspected deep tissue damage?

W.A wound cannot have two stages. Whole pressure ulcers should be judged by the deepest degree of tissue destruction in the wound, so in this case the wound is considered stage III. Grade III depth is deeper than the presumed deep tissue damage.

Q. I know that friction and shear contribute to pressure ulcers, but when should I do this? For example, the patient's elbow rubbed against the surface of the bed, leaving no epidermis. Is it an abrasion or a stage II pressure ulcer?

W.The situation you describe would be embarrassing.
It is worth considering the role of friction and bedsores. Friction occurs when two objects rub against each other. Friction is not the direct cause of pressure ulcers, but it can contribute to shear stresses in the skin and deeper tissue layers, which, when combined with pressure, cause pressure ulcers.5

(Video) Managing pressure ulcers - when is 'good' good enough?

Q. Can a patient get an ulcer caused by friction without pressure?

W.Friction occurs when two objects rub against each other. According to Hanson and colleagues, "friction rubs the skin of the epidermis and dermis, reducing the amount of pressure it takes to develop a pressure ulcer."6

Q. Can a patient get a stone wound without pressure?

W.Yes, but it's rare. Pressure on soft tissue, especially bony prominences, will cause some degree of displacement by deforming the tissue.2,5Shear stresses are due to forces applied tangentially to the surface and cause deformation of the object. Shear stresses usually occur in conjunction with compression.5

Q. The patient's belt has pierced the side and caused damage to the skin. Is this considered a bedsore?

W.Yes. The pressure, along with the friction caused by the tightening of the belt, is most likely the cause of skin damage, which can be considered a pressure ulcer.

Q. The patient has had a cast or appliance removed and the underlying skin has been damaged. Is it a bedsore?

W.Yes, this is considered a pressure ulcer and should be judged by the depth of tissue damage.

(Video) Hot Topics in Pressure Injuries and Wounds

Q. My patient has a pressure ulcer that is 100% filled with mucus and I have found that it cannot be staged. In addition to documenting the length and width, should I also try to specify the depth? Is it technically possible to achieve a depth of 0.1 cm?

W.Measuring depth in superficial wounds, moderate thickness wounds or necrotic wounds can be difficult. If the depth is less than 1 mm, document as "< 0.1 cm".7
Remember that if the wound is open, it will be deep because at least the epidermis has been penetrated. The epidermis has a thickness of 0.1 to 0.6 mm and the thickness of the dermis can vary from 2 to 4 mm.

Sources
National Pressure Ulcer Advisory Panel. Stages/categories of NPUAP pressure ulcers.
Pressure ulcer stage test. Practice your skills.

Bibliography
1. National Pressure Ulcer Advisory Panel. Facts about the reverse staging in 2000. Position of the NPUAP.http://www.npuap.org/wp-content/
uploads/2012/01/Reverse-Staging-Position-Statement%E2%80%A8.pdf
. Accessed 1 Nov 2012.

2. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guidelines. Washington, D.C.: National Pressure Pressure Advisory Panel; 2009.

3. Medicare and Medicaid service centers. OASIS-C September 2009 Implementation Guideline 2010 Chapter 3: F-1.vnaa.org/vnaa/g/?H=HTML/
doc/OASIS-C_ItemGuidance.pdf.
Accessed 1 Nov 2012.

4. Medicare and Medicaid Service Centers. RAI manual version 3.0. Section M. October 2011.

5. International Assessment. Pressure ulcer prevention: pressure, displacement, friction and microclimate in context. Consensus document. London: International Wounds; 2010.

(Video) Pressure Ulcers: The Model Health System (Q&A Session)

6. Hanson D, Langemo DK, Anderson J, Thompson P, Hunter S. Friction and shear considerations in pressure ulcer development.Advanced skin wound care. 2010 jan;23(1):21-4.

7. Hess CT.A clinical guide to skin and wound care. 7. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins; 2012; Hoofdstuk 2

Donna Sardina is the editor-in-chief of Wound Care Advisor and co-founder of the Wound Care Education Institute in Plainfield, Illinois.

FAQs

What is the staging system for pressure ulcers? ›

The stages are as follows: Stage I: The skin is intact with the presence of non-blanchable erythema. Stage II: There is partial-thickness skin loss involving the epidermis and dermis. Stage III: There is a full-thickness loss of skin that extends to the subcutaneous tissue but does not cross the fascia beneath it.

What is the best practice for a Stage 1 pressure ulcer? ›

For a stage I sore, you can wash the area gently with mild soap and water. If needed, use a moisture barrier to protect the area from bodily fluids. Ask your provider what type of moisture barrier to use. Stage II pressure sores should be cleaned with a salt water (saline) rinse to remove loose, dead tissue.

What are five 5 main criteria that should be included when examining and assessing a pressure injury? ›

Usual practice includes assessing the following five parameters:
  • Temperature.
  • Color.
  • Moisture level.
  • Turgor.
  • Skin integrity (skin intact or presence of open areas, rashes, etc.).

What are three 3 risk factors for pressure ulcers the nurse should review during the admission assessment? ›

Overall there is no single factor which can explain pressure ulcer risk, rather a complex interplay of factors which increase the probability of pressure ulcer development. Three primary risk factors include mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status.

What type of pressure injuries Cannot be staged? ›

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, injuries cannot be staged.

How do you classify wound stages? ›

Definition/Introduction
  1. Class 1 wounds are considered to be clean. They are uninfected, no inflammation is present, and are primarily closed. ...
  2. Class 2 wounds are considered to be clean-contaminated. ...
  3. Class 3 wounds are considered to be contaminated. ...
  4. Class 4 wounds are considered to be dirty-infected.
Apr 28, 2022

What are three teaching points for pressure ulcers? ›

Treat your skin gently to help prevent pressure ulcers.
  • When washing, use a soft sponge or cloth. ...
  • Use moisturizing cream and skin protectants on your skin every day.
  • Clean and dry areas underneath your breasts and in your groin.
  • Do not use talc powder or strong soaps.
  • Try not to take a bath or shower every day.
May 31, 2022

What interventions reduce pressure ulcers? ›

Treatments for pressure ulcers (sores) include regularly changing your position, using special mattresses to reduce or relieve pressure, and dressings to help heal the ulcer. Surgery may sometimes be needed.

Do you massage Stage 1 pressure ulcers? ›

Keep the skin clean and dry. Avoid massaging bony prominences. Provide adequate intake of protein and calories. Maintain current levels of activity, mobility and range of motion.

What are 3 nursing interventions to prevent pressure ulcers? ›

Patients managing pressure ulcers at home should be educated on proper infection prevention measures such as keeping dressings dry and intact, always washing hands before changing dressings, and monitoring for signs of infection to know when to alert the nurse or provider.

What are 2 assessment tools for pressure ulcers? ›

A number of tools have been developed for the formal assessment of risk for pressure ulcers. The three most widely used scales are the Braden Scale, the Norton Scale, and the Waterlow Scale.

What is the best position to prevent pressure ulcers? ›

Minimize friction and shear • Use 30-degree side lying position (alternating from the right side, the back and left side) to prevent pressure, sliding and shear- related injury.

What are 4 risk situations associated with pressure ulcer development? ›

Patients with heart failure and other chronic heart diseases that make blood flow sluggish are at risk. Those with kidney disease and anemia are also at risk. Patients with mental illness or Alzheimer's disease are at risk of bed sores. Cleansing with soap and water may raise risk of pressure sores.

What are the three most important dietary interventions for pressure ulcers wounds? ›

Consuming adequate protein, zinc and vitamin C can help a pressure ulcer heal. At times, a multivitamin/mineral supplement is necessary if adequate food cannot be consumed. However, it is always best to obtain adequate nutrition from foods first. Try to get at least one good source of vitamin C and zinc daily.

What are at least 5 risk factors for pressure ulcer development? ›

Risk factors
  • Immobility. This might be due to poor health, spinal cord injury and other causes.
  • Incontinence. Skin becomes more vulnerable with extended exposure to urine and stool.
  • Lack of sensory perception. ...
  • Poor nutrition and hydration. ...
  • Medical conditions affecting blood flow.

How often should you reposition a patient? ›

Changing a patient's position in bed every 2 hours helps keep blood flowing. This helps the skin stay healthy and prevents bedsores. Turning a patient is a good time to check the skin for redness and sores.

What is the most painful pressure injury stage? ›

Stage 4 pressure ulcers are the most serious. These sores extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments. In more severe cases, they can extend as far down as the cartilage or bone.

What does TNT stand for pressure ulcer? ›

In addition to turning, nutrition, and toileting, there are some other measures you can take to prevent pressure injuries.

What are the 4 Colours used to classify wounds? ›

While shading may vary, wound colors that are important to note typically fall into four categories: red, pink, yellow and black.

When should you not debride a wound? ›

The contraindications include, depending on the modality of mechanical debridement used, the presence of granulation tissue in a higher amount than the devitalized tissue, inability to control pain, patients with poor perfusion, and an intact eschar with no gross clinical evidence of an underlying infection.

What color should a healing wound be? ›

Wound bed. Healthy granulation tissue is pink in colour and is an indicator of healing. Unhealthy granulation is dark red in colour, often bleeds on contact, and may indicate the presence of wound infection. Such wounds should be cultured and treated in the light of microbiological results.

What is the #1 goal for pressure ulcers? ›

The process could include these steps: offer toileting, assess for needs of cleanliness, change wet surfaces, and offer water. turning/repositioning the patient is to reduce or eliminate pressure, thereby maintaining circulation to areas of the body at risk for pressure ulcers.

What are 4 terms used for pressure ulcers? ›

They are also known as 'bedsores', 'decubitus ulcers' although these names are now rarely used as it is recognised that the ulcers are not caused by lying or being in bed. The areas that are particularly prone to pressure sores are those that cover the bony areas such as occiput, trochanters, sacrum, malleoli and heel.

How often should a pressure ulcer dressing be changed? ›

Dressings should be changed regularly and as soon as they become soiled with urine or feces to prevent wound contamination. Each dressing change should be accompanied by concurrent wound reassessment.

How do you reposition patients to prevent pressure ulcers? ›

Repositioning by using the 30° tilt (left side, back, right side, back) every 3 hours during the night. Repositioning every 6 hours at night, using 90° lateral rotation.

What 8 points are important in preventing pressure ulcers? ›

The following tips can be used to help prevent the development of pressure ulcers.
  • 1 RISK ASSESSMENT. ...
  • 2 SKIN. ...
  • 3 SKIN CARE. ...
  • 4 MOISTURE. ...
  • 5 INCONTINENCE. ...
  • 6 NUTRITION. ...
  • 7 POSITION/MOBILITY. ...
  • 8 ERGONOMICS.

Which is better Blanchable or non Blanchable? ›

The authors conclude that people with non-blanching erythema are more likely to develop new pressure ulcers of Stage 2 or above within 28 days, than people without non-blanching erythema. It is important for medical staff to identify non-blanchable erythema and to intervene appropriately to prevent pressure ulcers.

How do you assess a pressure ulcer? ›

Intact skin surrounding the ulcer should be assessed for redness, warmth, induration or hardness, swelling, and any obvious signs of clinical infection. Pressure ulcer associated pain should be assessed prior to examination of the ulcer.

Can you change the stage of a pressure ulcer? ›

Once a pressure ulcer is”staged” it can progress to a higher stage but can NEVER be “BACK-STAGED REVERSE STAGED or DOWN STAGED”. Example: A Stage 3 pressure ulcer can worsen and become a Stage 4 but it NEVER becomes a Stage 2 as it heals.

What are the 5 key points to remember in relation to pressure area care? ›

SSKIN: 5 simple steps
  • Surface: Ensure the surfaces supporting you patient offer sufficient pressure relief.
  • Skin inspection: Early inspection enables early detection which is when ulcers are the easiest to treat.
  • Keep your patients moving: Regular body movement assists blood flow and redistributes pressure.

What is the best dressing for a Stage 2 pressure ulcer? ›

Currently, hydrocolloid dressings are widely used in individuals with Category/Stage II pressure ulcers. They are also used as primary dressings in the management of Category/Stage III and IV pressure ulcers that are healing well and have become shallow.

What is the major cause of pressure ulcers? ›

Pressure ulcers (also known as pressure sores or bedsores) are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time.

What is the Braden Scale for pressure ulcers? ›

The Braden Scale was developed by Barbara Braden and Nancy Bergstrom in 1988 and has since been used widely in the general adult patient population. The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development.

How often should pressure ulcers be reassessed? ›

All patients should undergo a pressure ulcer risk assessment within six hours of admission into an acute area of care. This should be regularly reviewed throughout their stay (NICE, 2005). This will help to identify those individuals who are more susceptible to pressure ulceration at the earliest stage.

Which tool predicts pressure ulcer risk? ›

The Braden Scale is a standardized tool to assess pressure ulcer risk that is reported for all hospitalized patients in the United States per requirements of the Center for Medicare and Medicaid Services.

What is 1 one of the most important ways to prevent pressure ulcers? ›

Regularly changing a person's lying or sitting position is the best way to prevent pressure ulcers. Special mattresses and other aids can help to relieve pressure on at-risk areas of skin. Most pressure ulcers (bedsores) arise from sitting or lying in the same position for a long time without moving.

What is the fastest way to heal a pressure ulcer? ›

Caring for a Pressure Sore
  1. Use special pillows, foam cushions, booties, or mattress pads to reduce the pressure. Some pads are water- or air-filled to help support and cushion the area. ...
  2. Change positions often. If you are in a wheelchair, try to change your position every 15 minutes.

What are the three most common early signs of pressure damage? ›

Early signs of pressure ulcer development include:
  • A change in the colour of the skin. ...
  • Reddening of the skin that does NOT turn white when you press it. ...
  • Any unusual changes in skin texture may be related to pressure damage. ...
  • A patch of skin that feels cooler or warmer to the touch than others.
Feb 26, 2020

What are the most vulnerable areas of pressure risk? ›

Common sites include the back of the head and ears, the shoulders, the elbows, the lower back and buttocks, the sit bones, the hips, the inner knees, and the heels. Pressure injuries may also form in places where the skin folds over itself. And they can occur where medical equipment puts pressure on the skin.

What are the two main intrinsic factors that cause development of a pressure ulcer? ›

Pressure ulcers are caused by intrinsic and extrinsic factors. The intrinsic factors include immobilization, cognitive deficit, chronic illness (eg, diabetes mellitus), poor nutrition, use of steroids, and aging. There are 4 extrinsic factors that can cause these wounds—pressure, friction, humidity, and shear force.

Which hospitalized patient is most at risk for a pressure ulcer? ›

Bed-ridden patients, especially those with spinal cord injuries, those who are hemodynamically unstable, the elderly and the very young are primarily at risk of developing pressure ulcers.

What is the most important nursing intervention for prevention of pressure ulcers? ›

Skin assessment is key to pressure injury prevention, classification/diagnosis, and treatment. All inpatients should have a skin assessment to determine its' general condition and identify factors that increase the risk for PI development.

What are the tools for pressure ulcer staging? ›

The three most widely used scales are the Braden Scale, the Norton Scale, and the Waterlow Scale. The Braden Scale,1,7,8 which is commonly used in the United States, consists of six items: sensory perception, moisture, activity, mobility, nutrition, and friction and shearing.

What are the 4 stages of pressure ulcers? ›

These are:
  • Stage 1. The area looks red and feels warm to the touch. ...
  • Stage 2. The area looks more damaged and may have an open sore, scrape, or blister. ...
  • Stage 3. The area has a crater-like appearance due to damage below the skin's surface.
  • Stage 4. The area is severely damaged and a large wound is present.

What is the difference between Stage 2 and DTI? ›

It is important to distinguish DTI from stage 2 pressure ulcers; a helpful difference is that stage 2 pressure ulcers do not have a dark wound bed. Blistering DTI is also often labelled as skin tears, even though there has been no trauma to this tissue.

What is the Braden scale score? ›

The Braden Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk is for developing an acquired ulcer or injury. There are six categories within the Braden Scale: sensory perception, moisture, activity, mobility, nutrition, and friction or shear.

What is Stage 2 and 3 pressure ulcer? ›

Stage 2: 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. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.

Which part of the body is most at risk of pressure ulcers? ›

They're most common on bony parts of the body, such as the heels, elbows, hips and base of the spine. They often develop gradually, but can sometimes form in a few hours.

What are the 3 terms for pressure ulcer? ›

Bedsores — also called pressure ulcers and decubitus ulcers — are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone.

Can a Stage 2 turn into a DTI? ›

The skin may open up superficially, which causes many clinicians to erroneously stage the DTI as a stage II pressure ulcer. Clinicians should continue to stage the wound as a DTI, but should describe the characteristics of how the skin is blistering or has superficial open areas.

Can a DTI become a Stage 3? ›

Should I document it as Stage 3 with deep tissue injury (DTI)? Answer: A wound cannot have two stages. Stage the entire pressure injury based upon the deepest level of tissue destruction. In this case, the wound would be considered Stage 3.

Is DTI considered pressure ulcer? ›

Deep tissue injury (DTI) is a form of pressure ulcer or pressure sore. Pressure ulcers are localized areas of tissue damage of necrosis that develop because of the pressure of a bony prominence.

What is the Braden score for pressure ulcers? ›

The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development. Generally, a score of 18 or less indicates at-risk status.

What are the risk assessment tools for pressure ulcers? ›

There are three commonly used pressure injury risk assessment tools: the Braden Scale, the Norton Scale and the Waterlow Scale. While these tools are evidence-based with significant scientific rigour and have become the standard in assessing for pressure injury risk, they do not capture risk in all patients.

What is a boggy heel? ›

Now, in medical terms, 'boggy' refers to abnormal texture of tissues characterized by sponginess, usually because of high fluid content. The NPIAP defines deep tissue injury as tissue that is painful, firm, mushy, warmer, or cooler to the touch compared with adjacent tissue. And 42% of all DTIs manifest on the heel.

What other preventive Cannot be used to treat a pressure ulcer? ›

Gauze dressings are not recommended for either the prevention or treatment of pressure ulcers.

Videos

1. Wound Classification: AHRQ Preventing Pressure Ulcers in Hospitals toolkit
(AHRQ Patient Safety)
2. Respiratory and Pressure Ulcers
(Saxe Healthcare Communications)
3. The Power of Nutrition: AHRQ Preventing Pressure Ulcers in Hospitals Toolkit
(AHRQ Patient Safety)
4. Let's discuss pressure injuries webinar
(Te Tāhū Hauora Health Quality & Safety Commission)
5. Clinical Aspects of Pressure Ulcer Care in LTC Facilities (Part 1 of 2)
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6. Conducting a Comprehensive Skin Assessment: AHRQ Preventing Pressure Ulcers in Hospitals toolkit
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References

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