Pressure Ulcers

• a localized area of tissue injury 
• caused by un relieved pressure 
• usually located over bony prominences
• resulting in damage of underlying tissue

• staging is used to describe the extent of tissue involvement in the ulcer 
• stage I,II,III,IV and unstageable 
• as stages increase, deeper tissues are involved

• 2 layers of skin: Epidermis=outer protective layer
• dermis=inner vascular layer
• Subcutaneous layers: fatty layer,
• muscle,
• tendon ligament,
• bone,
• joint capsule

• a defined area of persistent redness(doesn't blanche) in lightly pigmented skin 
• May appear with persistent red, blue, or purple hues in persons with darker skin tones 
• compared to surrounding skin, areas may be: warmer or cooler, firm or boggy, painful or itchy
• there is no open area in the skin

• With each repositioning, inspect the bony prominences(hips, sacrum, heel, coccyx) on which the person was lying
• inspect the heels (use a mirror if needed)

• Partial thickness skin loss involving epidermis and/or portions of dermis 
• ulcer is superficial

• partial thickness skin loss(shallow) 
• looks like an abrasion or blister
• normal surrounding skin

• inspect skin for shallow wounds or shiny areas of skin loss 
• do not classify skin tears, erosion from urine or feces as stage 2 
• don't include wounds covered with slough

• full thickness skin loss: damage or necrosis of subcutaneous tissue 
• may extend down to but not through underlying fascia 
• A deep crater with or without undermining of adjacent tissue

• full thickness skin loss (epidermis and dermis missing) 
• Ulcer bed may be subcutaneous fat, slough, necrosis or granulation tissue

• inspect all skin for wounds 
• do not label deep wounds covered with nonviable tissue as stage III . label them with unstageable 
• look for evidence of infection in ulcer :redness, swelling , pain, warmth , exudate

• full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures(tendon, joint capsule, etc.) 
• often associated with tunneling or undermining

• wound is deep 
• visible or palpable 
• may or may not have exposed tendon 
• may or may not have slough or eschar  
• may have undermining or tunneling

• inspect all skin for wounds 
• palpate or gently probe with sterile applicator to feel for bone
• do not label ulcers with necrotic tissues (eschar or slough) as stage IV, label them as unstageable

necrotic tissue that is moist, stringy, and yellow or gray(devitalized issue) is referred as slough

devitalized dermis that has become leathery or thick and black 

in a wound that is re-injured or suffered further avascular necrosis from compromised local circulation, the necrotic tissue turns thick, leathery and black. This tissue is referred to as eschar

an area of the ulcer beneath the skin surface that extends under the edge of the wound

• narrow extensions into the surrounding tissue from the sides of an ulcer 
• also called sinus tracts
• a fistula is a tunnel or sinus tract that ends in another structure or hollow viscous

ulcer is covered with eschar or slough and the true base of wound cannot be seen

• a new description of pressure ulcers. 
• a pressure related wound that begins in sub-dermal tissue 
• initially appears purple or blue, usually leads to denuding of the epidermis and eschar formation
• do not stage as stage I

• should be used for pressure ulcers only 
• other wounds should be described as fyll or partial thickness (eg, arterial ulcers-there is no staging system available)

• Meffitt-wagner Diabetic ulcer classification : 
• 0-Preulceration lesions, healed ulcers, presence of bony deformity
• 1-superficial ulcer with out subcutaneous tissue involvement 
• 2- penetration through the subcutaneous tissue; may expose bone, tendon, ligament, or joint capsule
• 3-Osteitis , abscess or osteomyelitis 
• 4-gangrene of digit 
• 5-gangrene of foot

• at the time of initial assessment or if ulcer deteriorates (the highest stage defines the wounds)
• when improving label ulcer with original stage as healing 
• do not document as stage II once it has started to heal(down-staging) : 
• deep tissue ulcers do not heal by replacing missing tissues 
• LTC- refer to minimum data set(MDS)

• sacrum--tail bone, most common site
• therefore avoid, semi fowlers position or slouching in bed or chair

• heels - second most common site 
• immobile or numb legs, leg traction
• higher risk in persons with peripheral vascular disease, hip fracture, and neuropathy from diabetes

• trochanter--hip bone :side lying, contracted patients at highest risk 
• lateral foot rather than heel itself:side lying, rotated foot 
• Ischium-sit here when erect: paraplegics at highest risk

• stages describe the level of tissue injury 
• stages to not indicate progression of ulcer development or healing 
• the NPUAP staging system is not appropriate for use with other types of wounds