Classification of pressure ulcers: Staging/Grading and Healing

Recommendations

Identify and Treat the Cause
1 Take a careful history Level of Evidence
Not Assessed
2 Conduct a head to toe skin inspection for pressure ulcers Level of Evidence
Not Assessed


Adress Patient-Centered Concerns
3 Provide individualized patient education Level of Evidence
Not Assessed


Provide Local Wound Care
4 Use the National Pressure Ulcer Advisory Panel (NPUAP) system to stage only pressure ulcers. Level of Evidence
Not Assessed
5 Use a validated tool, such as the NPUAP Pressure Ulcer Scale for Healing (PUSH), to monitor progress towards healing. Level of Evidence
Not Assessed


Provide Organizational Support
6 Establish and empower an interprofessional team to prevent, detect, stage and treat pressure ulcers Level of Evidence
Not Assessed


Background


Use of a common classification system assists in effective care planning, wound management and interdisciplinary team communication including across care settings.

Staging/Grading
The National Pressure Ulcer Advisory Panel (NPUAP) staging system should be used to stage pressure ulcers. The NPUAP system is designed to stage only pressure ulcers. Other types of wounds (for example, diabetic ulcers, skin tears, venous ulcers) should be staged or classified using systems developed for that wound type. It is inappropriate to use this staging system, which describes the ultimate depth of tissue affected in pressure ulcers, to describe healing (reverse staging), as full-thickness ulcers heal by granulation. The NPUAP system is widely accepted and uses six stages: (NPUAP Staging definitions used with permission)

Pressure Ulcer Stages

Suspected Deep Tissue Injury:
Purple or maroon localized areas of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a think blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Stage I:
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching: its color may differ from the surrounding area.

Further description:
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons ( a heralding sign of risk)

Stage II:
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.

Further description:
Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
* Bruising indicated suspected deep tissue injury

Stage III:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Further description:
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV:
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Further description:
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable
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 the wound bed.

Further description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Copyright: NPUAP 2007 www.npuap.org

Pressure Ulcer Healing
Each clinician makes a subjective assessment of objective criteria for each stage. Use of a tool to assess healing of pressure ulcers can confirm the effectiveness of a treatment plan or indicate the need for modifying the plan. Such a tool should not duplicate other wound assessments and should be user friendly, from the perspective of clinician time and education required for accurate use. Tools to assess healing of pressure ulcers include the Bates-Jensen Wound Assessment Toot (BWAT) (previously the Pressure Sore Status Tool (PSST)) and the NPUAP Pressure Ulcer Scale for Healing (PUSH).

The BWAT or PSST is a research-based tool that contains 15 wound assessment indices and generates a score, which allows an ulcer to be tracked over time. The requirement to document and tabulate 15 parameters at each assessment may impact on a clinician’s decision to use or not use this tool in practice.

The PUSH tool was designed as a quick and reliable tool to monitor pressure ulcers over time. The PUSH tool has been validated in 2 multicentre retrospective studies and a pilot test. This tool assigns scores to 3 indices which are area (length multiplied by width), greatest wound length and greatest width, exudate amounts (none, light, moderate, heavy) and tissue types (closed, epithelial tissue, granulation tissue, slough and necrotic tissue). The sum of the scores is recorded and plotted. Decreasing scores indicate healing, whereas increasing scores indicate deterioration.

References

Essential Publications
1 PUSH Tool Quality Indicator
 Type: Validation study
Thomas DR, Rodeheaver GT, Bartolucci AA, Franz RA, Sussman C, Ferrell BA, Cuddigan J, Stotts NA, Maklebust J. Pressure ulcer scale for healing: Derivation and validation of the PUSH tool. Adv Wound Care 1997;10(5):96–101.
This article describes the development of the PUSH Tool by literature review and expert opinion. Content validity was established by correlation between PUSH Tool scores and acetate tracings r = 0.70 – 0.83. The initial estimate of responsivenes, or the ability to detect change, was inferred when change was observed in bi-weekly evaluations, the scores being consistent with outcome (healing).
2 PUSH Tool Quality Indicator
 Type: Validation study
Gardner SE, Frantz RA, Bergquist S, Shin CD. A prospective study of the pressure ulcer scale for healing (PUSH). J of Gerontology 2005;60A(1):93-97.
This article demonstrates further the responsiveness of the PUSH Tool. Change in PUSH Tool scores were detected in healed wounds versus lack of change in unhealed wounds found in prospective study.
3 PUSH Tool Quality Indicator
 Type: Validation study
Stotts NA, Rodeheaver GT, Thomas DR, Frantz RA, Bartolucci AA, Sussman C, Ferrell BA, Cuddigan J, Maklebust J. An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH). J of Gerontology 2001; 56A(12): M795-M799.
This article illustrates further evidence that the PUSH Tool is responsive to change. Change over 12 weeks was detected in multiple regression analysis of secondary data.
4 PUSH Tool - Use in RCT Quality Indicator
 Type: RCT
Lee SK, Posthauer ME, Dorner B, Redovian V, Maloney MJ. Pressure ulcer healing with a concentrated, fortified, collagen protein hydrolysate supplement: a randomized controlled trial. Advances in Skin and Wound Care 2006;19(2): 92-96
This article illustrates that the PUSH Tool may be useful to detect a difference between groups in RCT. change from baseline to 8 weeks was detected in treatment and control groups in this RCT of concentrated, fortified, collagen protein hydrolysate supplement.


Enablers for practice

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