Von Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Pressure ulcer staging can be challenging. Here are some frequently asked questions - and answers - about grooming.
Q.If a decubitus heals (completely epithelialized) but then tears again in the same location, how should it be staged?
ONE.According to the National Pressure Ulcer Advisory Panel, if a pressure ulcer recurs in the same location, the ulcer should be recorded in the previous stage.
Diagnostic (eg if it was stage IV before it closed, it would be stage IV when it reopened).1
Remember that pressure sores always heal more superficially. They do not replace lost muscle, subcutaneous fat, or lost dermis prior to re-epithelialization. In contrast, the ulcer cap is filled with scar tissue composed primarily of endothelial cells, fibroblasts, collagen, and extracellular matrix. Therefore, a stage IV pressure ulcer cannot become a stage III, II, or later stage I pressure ulcer.1
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Q. Can pressure ulcer staging be used for venous ulcers?
ONE.No. The National Pressure Ulcer Advisory Board and the European Pressure Ulcer Advisory Board state that a pressure ulcer classification system cannot be used to describe tissue loss in wounds that are not pressure ulcers.2
Q. If a wound initially presents as a suspected deep tissue injury (DSTI) and then ruptures, should I document it as a healing SDTI or reassess it as it presents?
ONE.Staging is based on the deepest level of tissue destruction through the skin layers. So stage according to the level of destruction you see and/or feel. So if the characteristics of the ulcer change, you should reassess it based on what you see.
Remember to read the definitions for each stage. If you can't tell exactly what you see, document the wound as unclassifiable.
Q. Once removed, does the pressure ulcer become a surgical wound and no longer need to be evaluated?
ONE.According to the Centers for Medicare and Medicaid Services (CMS), a surgically removed pressure ulcer remains a pressure ulcer and is not considered a surgical wound.3,4
Q. What would be the new stage for a stage II pressure ulcer that develops with a splint?
ONE.As grading is based on the deepest level of tissue destruction through the skin layers, you will grade the ulcer according to the level of destruction you see and/or feel.
If a stage II ulcer is so crusted over that you cannot see or feel the deeper level of tissue destruction, it is considered unstaged. However, if scattered superficial plaque is present and the deeper level of tissue destruction is visible or palpable, the ulcer is Stage III or Stage IV.
Q. If a stage IV pressure ulcer is repaired with a surgical flap, is it still a stage IV pressure ulcer or not indicative?
ONE.According to CMS, when a muscle flap, skin advancement flap, or rotation flap is used 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
code the area as a surgical wound until it heals.3,4
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?
ONE.A wound cannot have two stages. The classification of total pressure ulcer should be based on the deepest degree of tissue destruction in the ulcer. In this case, the wound will be considered as stage III. A stage III depth is deeper than a suspected deep tissue injury.
Q. I know friction and shear contribute to the development of pressure ulcers, but when should I classify them? For example, a patient's elbow was rubbing the surface of the bed, causing shedding of the epidermis. Is it a scratch or a stage II recumbency?
ONE.The situation you describe would be friction.
The role of friction and pressure sores is worth considering. The force of friction occurs when two objects rub against each other. Friction is not a direct cause of pressure ulcers, but can create shear stresses in the skin and deeper tissues that combine with pressure to cause pressure ulcers.5
Q. Can a patient have a non-pressure abrasion?
ONE.The force of friction occurs when two objects rub against each other. According to Hanson and colleagues, "friction breaks down the epidermis and dermis of the skin, thereby reducing the pressure required for pressure ulcer development."6
Q. Can a patient sustain a shear injury without pressure?
ONE.Yes, but it rarely happens. Pressure on soft tissues, particularly over a bony prominence, results in some shear due to tissue deformation.2,5Shear stresses are created by forces applied to a surface and cause the object in question to deform. Shear stresses usually occur in conjunction with pressure.5
F. A patient's belt was sinking into his side causing skin damage. Does this count as a flood/ulcer?
ONE.Yes. The pressure and friction from the tightening of the waistband is probably the cause of the skin damage and this could be considered a pressure ulcer.
Q. A cast or splint is removed from a patient and there is damage to the skin underneath. Is it a pressure sore/ulcer?
ONE.Yes, this would be considered a pressure ulcer and should be graded according to the depth of tissue destruction.
Q. My patient has a 100% crusted pressure ulcer and I have determined that it is not staged. In addition to documenting the length and width, should I also try to determine the depth? Is it technically possible to reach a depth of 0.1 cm?
ONE.It can be difficult to gauge the depth of superficial ulcers, some of which are thick or crusted wounds. If the depth is less than 1 mm, document it as "< 0.1 cm."7
Remember that an open wound is deep as long as the skin has at least been penetrated. The epidermis is 0.1 to 0.6 mm thick, and the thickness of the skin can vary from 2 to 4 mm.
•National Pressure Ulcer Advisory Committee. NPUAP pressure ulcer stages/categories.
•Pressure Ulcer Staging Test. Practice your skills.
1. National Pressure Ulcer Advisory Council. The facts about the reverse stage in 2000. The NPUAP position statement.http://www.npuap.org/wp-content/
uploads/2012/01/Reverse-Staging-Position-Statement%E2%80%A8.pdf. Accessed November 1, 2012.
2. National Pressure Ulcer Advisory Board and European Pressure Ulcer Advisory Board. Prevention and treatment of pressure ulcers: a clinical practice guide. Washington, DC: National Pressure Ulcer Advisory Council. 2009
3. Centers for Medicare and Medicaid Services. OASIS-C September 2009 Implementation Guide 2010 Chapter 3: F-1.vnaa.org/vnaa/g/?H=HTML/
doc/OASIS-C_ItemGuidance.pdf.Accessed November 1, 2012.
4. Centers for Medicare and Medicaid Services. RAI Manual Version 3.0. Section M. October 2011.
5. International inspection. Pressure ulcer prevention: Pressure, shear, friction and microclimate in the framework. Consent document. London: Wounds International; 2010
6. Hanson D, Langemo DK, Anderson J, Thompson P, Hunter S. Friction and shear considerations in the development of pressure ulcers.Adv treatment of skin wounds. 2010 Jan. 23(1):21-4.
7. CT de Hess.Clinical Guide to Skin and Wound Care. 7th edition Philadelphia, PA: Lippincott Williams & Wilkins; 2012? Chapter 2.
Donna Sardina is editor-in-chief of Wound Care Advisor and co-founder of the Wound Care Education Institute in Plainfield, Illinois.