By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Show Staging pressure ulcers can be challenging. Below are some common questions—and answers—about staging. Q. If a pressure ulcer heals (completely epithelialized over), but later reopens at the same site, how should it be staged? A. According to the National Pressure Ulcer Advisory Panel, if a pressureulcer reopens in the same site, the
ulcer should be listed at the previous staging Q. Can pressure ulcer staging be used for venous ulcers? A. No. The National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel state that a pressure ulcer classification system can’t be used to describe tissue loss in wounds other than pressure ulcers.2 Q. If a wound first presents as a suspected deep-tissue injury (SDTI) and then becomes open, should I chart it as a healing SDTI or restage it as it presents? A. Staging is based on the deepest level of tissue destruction through the layers of skin; therefore, you stage according to what level of destruction you see and/or feel. So, as the ulcer changes characteristics, you should restage it based upon what you see. Q. Once a pressure ulcer is debrided, does it become a surgical wound and no longer need staging? A. According to the Centers for Medicare & Medicaid Services (CMS), a pressure ulcer that has been surgically debrided remains a pressure ulcer, and isn’t considered a surgical wound.3,4 Q. What would be the new stage for a Stage II pressure ulcer that develops slough? A. Because staging is based on the deepest level of tissue destruction through the layers of skin, you would stage the ulcer according to the level of destruction you see and/or feel. Q. If a Stage IV pressure ulcer is repaired with a surgical flap, would it still be a Stage IV or would it be unstageable? A. According to the CMS, if a muscle flap, skin advancement flap, or rotational flap is performed to surgically replace a pressure ulcer, the area is considered a surgical wound and is no longer a pressure ulcer. If the flap fails, continue Q. Can a wound have two stages? My patient has a Stage III pressure ulcer, but I also see dark purple around part of it. Should I document it as Stage III with suspected deep-tissue injury? A. A wound can’t have two stages. The entire pressure ulcer should be staged based upon the deepest level of tissue destruction in the ulcer, so in this case the wound would be considered Stage III. A Stage III depth is deeper than a suspected deep-tissue injury. Q. I know that friction and shearing contribute to pressure ulcer development but when do I stage it? For example, a patient’s elbow has rubbed across the surface of the bed, resulting in missing epidermis. Is this now an abrasion or a Stage II pressure ulcer? A. The situation you describe would be an abrasion. Q. Can a patient have a friction wound without pressure? A. Friction force occurs when two objects rub against each other. According to Hanson and colleagues, “Friction abrades the skin of the epidermis and dermis, thereby decreasing the amount of pressure needed to create a pressure ulcer.”6 Q. Can a patient have a shearing wound without pressure? A. Yes, but it’s rare. Pressure on soft tissues, especially when over a bony prominence, will cause some degree of shear through tissue distortion.2,5 Shear stresses arise from forces applied tangentially to a surface and cause deformation of the object involved. Shear stresses usually occur in combination with pressure.5 Q. A patient’s waistband dug into his side and caused skin breakdown. Is this considered a pressure ulcer? A. Yes. Pressure along with friction from the constriction of the waistband is most likely the cause of the skin breakdown, and this would be considered a pressure ulcer. Q. A patient has a cast or device removed and there is skin breakdown underneath. Is this a pressure ulcer? A. Yes, this would be considered a pressure ulcer and would need to be staged according to depth of the tissue destruction. Q. My patient has a pressure ulcer that is 100% filled with slough, and I’ve determined it’s unstageable. In addition to documenting length and width, should I also try to determine a depth? Can you technically have a depth that is 0.1 cm? A. It can be difficult to
measure depth in superficial partial-thickness ulcers or wounds covered with slough. If the depth is less than 1 mm, document as “< 0.1 cm.”7 Resources References 2. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009. 3. Centers for Medicare & Medicaid Services. OASIS-C Guidance Manual September 2009 for 2010 Implementation Chapter 3: F-1. vnaa.org/vnaa/g/?H=HTML/ 4. Centers for Medicare & Medicaid Services. RAI Version 3.0 Manual. Section M. October 2011. 5. International Review. Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document. London: Wounds International; 2010. 6. Hanson D, Langemo DK, Anderson J, Thompson P, Hunter S. Friction and shear considerations in pressure ulcer development. Adv Skin Wound Care. 2010 Jan;23(1):21-4. 7. Hess CT. Clinical Guide to Skin and Wound Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012;chap 2. Donna Sardina is Editor-in-Chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois. What is a Stage 3 pressure injury?Stage 3 bedsores (also known as stage 3 pressure sores, pressure injuries, or decubitus ulcers) are deep and painful wounds in the skin. They are the third of four bedsore stages. These sores develop when a stage 2 bedsore penetrates past the top layers of skin but has yet not reached muscle or bone.
What Is a Stage 2 pressure injury?At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid.
What is a Stage 1 pressure injury?Stage 1 pressure injuries are characterized by superficial reddening of the skin (or red, blue or purple hues in darkly pigmented skin) that when pressed does not turn white (non-blanchable erythema). If the cause of the injury is not relieved, these will progress and form proper ulcers.
How would you identify a Stage 2 pressure injury?Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. In stage 2 pressure injuries there is a partial-thickness loss of skin with exposed dermis. The wound bed is pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Fat and deeper tissues are not visible.
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Which stage pressure injury would the nurse suspect in a patient who has an abrasion with partial epidermal loss?
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