Wound Care Management
Pressure Ulcer Staging—Revisited Marcia Spear, DNP, ACNP-BC, CWS, CPSN A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence and is a result of pressure or pressure in combination with shear and/or friction. Staging systems have and continue to give a clinical description of the depth of tissue destruction that occurs with a pressure ulcer. Numerous staging systems have been developed including one by Guttman (1956) in 1955. In 1975, Shea, an orthopedic surgeon, developed the first well-documented method that consisted of a numeric classification system Grades I–IV and included a closed pressure sore based on pathology. Shea (1975) described each stage by the amount and type of soft tissue damage and included Grade I as an acute inflammatory response Marcia Spear, DNP, ACNP-BC, CWS, CPSN received her Doctor of Nursing Practice from Vanderbilt University School of Nursing. She is faculty at both the School of Medicine and the School of Nursing at Vanderbilt University. She has more than 20 years of experience in plastic surgery and wound care and is presently working as a nurse practitioner and a certified wound specialist for the Department of Plastic Surgery at Vanderbilt University Medical Center. She is currently President Elect of the American Society of Plastic Surgical Nursing. The author reports no conflicts of interest. Address correspondence to Marcia Spear, DNP, ACNP-BC, CWS, CPSN, Department of Plastic Surgery, Vanderbilt University Medical Center, S-2221 Medical Center North, Nashville, TN 37232 (e-mail: marcia.spear@ vanderbilt.edu). DOI: 10.1097/PSN.0000000000000015
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while Grade IV was described as penetrating fascia with severe undermining. The closed pressure ulcer described by Shea was similar to the current definition of suspected deep tissue injury (DTI) and will be discussed later. The International Association of Enterostomal Therapist, now known as the Wound Ostomy and Continence Nurses Society, developed a four-stage classification system in 1988. Although other staging and classification systems (Barton, 1976; Campbell, 1959; Daniel, Priest, & Wheatley, 1981) were developed, Shea’s system was the most widely used until the 1980s (Black et al., 2007). The European Pressure Ulcer Advisory Panel also has a staging system developed in 1998 consisting of four stages: Grade 1–Grade 4. The most widely accepted and utilized classification system today is the one presented by the National Pressure Ulcer Advisory Panel (NPUAP) in 1989. This classification system has undergone updates and revisions due to a greater understanding of the pathogenesis and clinical research associated with pressure ulcers. This column presents the current NPUAP staging system.
NPUAP The NPUAP is an independent not-for-profit professional organization dedicated to the prevenPlastic Surgical Nursing
❙
tion and management of pressure ulcers. The NPUAP was formed in 1987 as a national multidisciplinary health care advocacy organization dedicated to preventing and improving the care of individuals with pressure ulcers and to increase public awareness of this problem. The NPUAP is currently composed of leading experts from different health disciplines that share a commitment to prevent and manage pressure ulcers. The NPUAP serves as a resource and an authoritative voice to health care professionals, the government, health care agencies, and the public. It consists of a Board of Directors, a Corporate Advisory Council, a Collaborating Organizations Council, a Providers Advisory Council, and an Alumni Council of past board members. Three committees, education, public policy, and research, work toward meeting the NPUAP’s goal of providing multidisciplinary leadership for improved patient outcomes in pressure ulcer prevention and management (www.npuap.org). Education of both providers and patients has always been a primary focus of the NPUAP. The NPUAP has held a consensus conference every 2 years since 1989. The purpose of these consensus conferences has been to enhance awareness of the seriousness of the national pressure ulcer problem and reach a consensus among health care providers and
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researchers on approaches to the prevention, diagnosis, management, and treatment of pressure ulcers. During the first consensus conference in 1989, the NPUAP developed a four-stage classification system similar to systems that were currently being used at the time. During this conference, the NPUAP also made recommendations for tracking pressure ulcer prevalence and incidence. The conferences in 1991 and 1993 focused on the prediction, prevention, and treatment of pressure ulcers. In 1995, the conference focused on pressure ulcer healing and the staging system. Other conferences have focused on the inappropriateness of reverse staging, guidance on the early identification of pressure ulcers, avoidable versus unavoidable pressure ulcers, the state of pressure ulcers in America, and the pathogenesis and evolution of DTI (Langemo, Black, Maklebust, & Posthauer, 2007). The NPUAP has been instrumental and active in promoting and developing public policy relating to pressure ulcer prevention and management. Some of their work includes adding language to a bill in 1988 that upgraded the criteria for nursing assistants in long-term care. Members of this committee have been active in Washington, DC, and the NPUAP consensus statement was used to document the importance of pressure ulcer prevention in Healthy People 2000 but never made the final version of objectives. The NPUAP was invited to submit a pressure ulcer objective for Healthy People 2010 and this time was included in the final version. The NPUAP has campaigned for coverage and payment of dressing materials and support surfaces. They continue to be a voice in public policies. The NPUAP has published more than 20 publications including manuscripts, monographs, assessment tools, and other publications in numerPlastic Surgical Nursing
❙
ous peer-reviewed journals. Their many accomplishments and diligent work on the prevention and management of pressure ulcers have clearly paved the way as the national authority on pressure ulcers.
PRESSURE ULCER STAGES The first staging system developed by the NPUAP was in 1989. Over the years, the staging system has continued to evolve as research and clinical expertise has heightened our understanding of the development and pathology of pressure ulcers. After years of research, discussion, and consensus building, the NPUAP pressure ulcer staging system was updated in 2007 and is the most widely used system to date (NPUAP, 2007). The ultimate goal of this staging system was to clarify each stage and reduce the number of incorrectly staged ulcers or other types of wounds and skin lesions. A new stage was added in the updated 2007 system called suspected DTI. Following is a list of the current staging system and it must be emphasized that this system is for staging pressure ulcers only and is not to be used for wounds of other etiologies. Also, worthy to note is that once a pressure ulcer is staged IV, it does not become a stage III as it heals but becomes a healing Stage IV. Pressure ulcers should never be back-staged (Table). Suspected deep tissue injury. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft issue from pressure and/or shear. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. May be difficult to detect with dark skin tones. Stage I. Intact skin with nonblanchable redness or a localized area usually over a bony
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prominence. May be difficult to detect in individuals with dark skin tones. Stage II. Partial-thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III. Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
TABLE. Staging for Pressure Ulcers Stage
Description
Deep tissue injury
Purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage of underlying soft issue from pressure and/or shear.
I
Intact skin with nonblanchable redness Usually located over a bony prominence
II
Partial-thickness loss of dermis Shallow open ulcer with red/pink wound bed No slough Intact/open serum filled blister
III
Full-thickness tissue loss Subcutaneous tissue may be visible Bone, tendon, or muscle not exposed
IV
Full-thickness tissue loss Bone, tendon, and muscle exposed Slough or eschar may be present
Unstageable
Full-thickness tissue loss Base of ulcer covered by slough and/or eschar True depth of ulcer cannot be determined
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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 includes undermining and tunneling. 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). Until enough slough and/or eschar are removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.
CONCLUSION As with any staging system there can be errors in utilization. This system is for pressure ulcers only
194
and should not be used for other wound types. Knowledge of the skin anatomy and deeper tissue layers is necessary to properly stage. Improper staging can result in inappropriate prevention and treatment interventions and misuse of resources and carries the potential for litigation. Accurate staging is necessary for treatment planning and communication between health care providers.
REFERENCES Barton, A. (1976). The pathogenesis of skin wounds due to pressure. In R. M. Kenedi, J. M. Cowden, & J. T. Scales (Eds.), Bed sore biomechanics (pp. 55–62). London: Macmillan Press. Black, J., Baharestani, M., Gudigan, J., Dorner, B., Edsberg, L., Langemo, D., et al. (2007). National Pressure Ulcer Advisory Panel’s updated pres-
Plastic Surgical Nursing
❙
sure ulcer staging system. Urology Nursing, 27(2), 144–150. Campbell, R. (1959). The surgical management of pressure sores. Surgical Clinics of North America, 59, 509–513. Daniel, R., Priest, D., & Wheatley, D. (1981). Etiologic factors in pressure sores: An experimental model. Archives of Physical Medicine and Rehabilitation, 62, 492–498. Guttman, L. (1956). The problem of treatment of pressure sores in spinal paraplegics. British Journal of Plastic Surgery, 8, 196. Langemo, D., Black, J., Maklebust, J., & Posthauer, M. (2007). The NPUAP: Look who else is turning 20!. Advances in Skin and Wound Care, 20(2), 84–89. Shea, J. (1975). Pressure sores classification and management. Clinical Orthopaedics, 112, 89–100. The National Pressure Ulcer Advisory Panel. (2007). Pressure ulcer category/ staging illustrations. Retrieved September 6, 2013 from http://www. npuap.org
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Pressure Ulcer Staging—Revisited Marcia Spear, DNP, ACNP-BC, CWS, CPSN A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence and is a result of pressure or pressure in combination with shear and/or friction. Staging systems have and continue to give a clinical description of the depth of tissue destruction that occurs with a pressure ulcer. Numerous staging systems have been developed including one by Guttman (1956) in 1955. In 1975, Shea, an orthopedic surgeon, developed the first well-documented method that consisted of a numeric classification system Grades I–IV and included a closed pressure sore based on pathology. Shea (1975) described each stage by the amount and type of soft tissue damage and included Grade I as an acute inflammatory response Marcia Spear, DNP, ACNP-BC, CWS, CPSN received her Doctor of Nursing Practice from Vanderbilt University School of Nursing. She is faculty at both the School of Medicine and the School of Nursing at Vanderbilt University. She has more than 20 years of experience in plastic surgery and wound care and is presently working as a nurse practitioner and a certified wound specialist for the Department of Plastic Surgery at Vanderbilt University Medical Center. She is currently President Elect of the American Society of Plastic Surgical Nursing. The author reports no conflicts of interest. Address correspondence to Marcia Spear, DNP, ACNP-BC, CWS, CPSN, Department of Plastic Surgery, Vanderbilt University Medical Center, S-2221 Medical Center North, Nashville, TN 37232 (e-mail: marcia.spear@ vanderbilt.edu). DOI: 10.1097/PSN.0000000000000015
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while Grade IV was described as penetrating fascia with severe undermining. The closed pressure ulcer described by Shea was similar to the current definition of suspected deep tissue injury (DTI) and will be discussed later. The International Association of Enterostomal Therapist, now known as the Wound Ostomy and Continence Nurses Society, developed a four-stage classification system in 1988. Although other staging and classification systems (Barton, 1976; Campbell, 1959; Daniel, Priest, & Wheatley, 1981) were developed, Shea’s system was the most widely used until the 1980s (Black et al., 2007). The European Pressure Ulcer Advisory Panel also has a staging system developed in 1998 consisting of four stages: Grade 1–Grade 4. The most widely accepted and utilized classification system today is the one presented by the National Pressure Ulcer Advisory Panel (NPUAP) in 1989. This classification system has undergone updates and revisions due to a greater understanding of the pathogenesis and clinical research associated with pressure ulcers. This column presents the current NPUAP staging system.
NPUAP The NPUAP is an independent not-for-profit professional organization dedicated to the prevenPlastic Surgical Nursing
❙
tion and management of pressure ulcers. The NPUAP was formed in 1987 as a national multidisciplinary health care advocacy organization dedicated to preventing and improving the care of individuals with pressure ulcers and to increase public awareness of this problem. The NPUAP is currently composed of leading experts from different health disciplines that share a commitment to prevent and manage pressure ulcers. The NPUAP serves as a resource and an authoritative voice to health care professionals, the government, health care agencies, and the public. It consists of a Board of Directors, a Corporate Advisory Council, a Collaborating Organizations Council, a Providers Advisory Council, and an Alumni Council of past board members. Three committees, education, public policy, and research, work toward meeting the NPUAP’s goal of providing multidisciplinary leadership for improved patient outcomes in pressure ulcer prevention and management (www.npuap.org). Education of both providers and patients has always been a primary focus of the NPUAP. The NPUAP has held a consensus conference every 2 years since 1989. The purpose of these consensus conferences has been to enhance awareness of the seriousness of the national pressure ulcer problem and reach a consensus among health care providers and
October–December 2013
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Copyright © 2013 American Society of Plastic Surgical Nurses. Unauthorized reproduction of this article is prohibited.
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researchers on approaches to the prevention, diagnosis, management, and treatment of pressure ulcers. During the first consensus conference in 1989, the NPUAP developed a four-stage classification system similar to systems that were currently being used at the time. During this conference, the NPUAP also made recommendations for tracking pressure ulcer prevalence and incidence. The conferences in 1991 and 1993 focused on the prediction, prevention, and treatment of pressure ulcers. In 1995, the conference focused on pressure ulcer healing and the staging system. Other conferences have focused on the inappropriateness of reverse staging, guidance on the early identification of pressure ulcers, avoidable versus unavoidable pressure ulcers, the state of pressure ulcers in America, and the pathogenesis and evolution of DTI (Langemo, Black, Maklebust, & Posthauer, 2007). The NPUAP has been instrumental and active in promoting and developing public policy relating to pressure ulcer prevention and management. Some of their work includes adding language to a bill in 1988 that upgraded the criteria for nursing assistants in long-term care. Members of this committee have been active in Washington, DC, and the NPUAP consensus statement was used to document the importance of pressure ulcer prevention in Healthy People 2000 but never made the final version of objectives. The NPUAP was invited to submit a pressure ulcer objective for Healthy People 2010 and this time was included in the final version. The NPUAP has campaigned for coverage and payment of dressing materials and support surfaces. They continue to be a voice in public policies. The NPUAP has published more than 20 publications including manuscripts, monographs, assessment tools, and other publications in numerPlastic Surgical Nursing
❙
ous peer-reviewed journals. Their many accomplishments and diligent work on the prevention and management of pressure ulcers have clearly paved the way as the national authority on pressure ulcers.
PRESSURE ULCER STAGES The first staging system developed by the NPUAP was in 1989. Over the years, the staging system has continued to evolve as research and clinical expertise has heightened our understanding of the development and pathology of pressure ulcers. After years of research, discussion, and consensus building, the NPUAP pressure ulcer staging system was updated in 2007 and is the most widely used system to date (NPUAP, 2007). The ultimate goal of this staging system was to clarify each stage and reduce the number of incorrectly staged ulcers or other types of wounds and skin lesions. A new stage was added in the updated 2007 system called suspected DTI. Following is a list of the current staging system and it must be emphasized that this system is for staging pressure ulcers only and is not to be used for wounds of other etiologies. Also, worthy to note is that once a pressure ulcer is staged IV, it does not become a stage III as it heals but becomes a healing Stage IV. Pressure ulcers should never be back-staged (Table). Suspected deep tissue injury. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft issue from pressure and/or shear. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. May be difficult to detect with dark skin tones. Stage I. Intact skin with nonblanchable redness or a localized area usually over a bony
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prominence. May be difficult to detect in individuals with dark skin tones. Stage II. Partial-thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III. Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
TABLE. Staging for Pressure Ulcers Stage
Description
Deep tissue injury
Purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage of underlying soft issue from pressure and/or shear.
I
Intact skin with nonblanchable redness Usually located over a bony prominence
II
Partial-thickness loss of dermis Shallow open ulcer with red/pink wound bed No slough Intact/open serum filled blister
III
Full-thickness tissue loss Subcutaneous tissue may be visible Bone, tendon, or muscle not exposed
IV
Full-thickness tissue loss Bone, tendon, and muscle exposed Slough or eschar may be present
Unstageable
Full-thickness tissue loss Base of ulcer covered by slough and/or eschar True depth of ulcer cannot be determined
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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 includes undermining and tunneling. 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). Until enough slough and/or eschar are removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.
CONCLUSION As with any staging system there can be errors in utilization. This system is for pressure ulcers only
194
and should not be used for other wound types. Knowledge of the skin anatomy and deeper tissue layers is necessary to properly stage. Improper staging can result in inappropriate prevention and treatment interventions and misuse of resources and carries the potential for litigation. Accurate staging is necessary for treatment planning and communication between health care providers.
REFERENCES Barton, A. (1976). The pathogenesis of skin wounds due to pressure. In R. M. Kenedi, J. M. Cowden, & J. T. Scales (Eds.), Bed sore biomechanics (pp. 55–62). London: Macmillan Press. Black, J., Baharestani, M., Gudigan, J., Dorner, B., Edsberg, L., Langemo, D., et al. (2007). National Pressure Ulcer Advisory Panel’s updated pres-
Plastic Surgical Nursing
❙
sure ulcer staging system. Urology Nursing, 27(2), 144–150. Campbell, R. (1959). The surgical management of pressure sores. Surgical Clinics of North America, 59, 509–513. Daniel, R., Priest, D., & Wheatley, D. (1981). Etiologic factors in pressure sores: An experimental model. Archives of Physical Medicine and Rehabilitation, 62, 492–498. Guttman, L. (1956). The problem of treatment of pressure sores in spinal paraplegics. British Journal of Plastic Surgery, 8, 196. Langemo, D., Black, J., Maklebust, J., & Posthauer, M. (2007). The NPUAP: Look who else is turning 20!. Advances in Skin and Wound Care, 20(2), 84–89. Shea, J. (1975). Pressure sores classification and management. Clinical Orthopaedics, 112, 89–100. The National Pressure Ulcer Advisory Panel. (2007). Pressure ulcer category/ staging illustrations. Retrieved September 6, 2013 from http://www. npuap.org
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Copyright © 2013 American Society of Plastic Surgical Nurses. Unauthorized reproduction of this article is prohibited.
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