IssueBy Nancy Morgan, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
Staging pressure ulcers can get tricky, especially when we’re dealing with a suspected deep-tissue injury (SDTI). The National Pressure Ulcer Advisory Panel defines an SDTI as a “purple or maroon localized area 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… Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin 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.”
The key difference between this type of ulcer and an unstageable pressure ulcer is that SDTI involves intact skin, whereas an unstageable ulcer involves a breakdown into at least the subcutaneous tissue. An unstageable ulcer is covered with necrotic tissue, such as slough or eschar, formed from remnants of the collagen matrix of subcutaneous tissue. So it’s always a full-thickness ulcer—either stage III or stage IV.
An SDTI tends to confuse clinicians because of the “intact skin” criterion. Damage from an SDTI occurs at the soft-tissue interface and extends out toward the skin surface. The skin remains intact, but the damage has occurred deeper than the eye can see and involves full-thickness structures. If an SDTI opens, the clinician stages the ulcer based on the tissue type and/or structures assessed in the wound bed.
Do you see staging being done correctly in the field? Do you have any tips on staging pressure ulcers?
Does a wound bed have to be completely covered with eschar or slough to be considered upstageable? I have a nurse at my agency that says it does.
Tara, no it doesn’t. Sometimes you may have only 80% necrotic tissue in the site and 20% granulation tissue that would still be unstagable cause you really don’t know what is underneath the 80% necrotic tissue. What I usually say is “ride the unstagable ride” til you are professionally comfortable with putting a stage on it. So wait til you are able to see some “identifiable tissue/structures” present before putting a stage to it.
What I have seen in the field is that many see the necrotic tissue being removed and call it a st.III, then once all the necrotic tissue is removed they now see bone and now have to up-stage it to a IV. Which only red flags the facility that they made the wound worse. Hope this helps. I have a free 1 hr pressure ulcer staging webinar on my website: http://www.wcei.net click courses and locations…….then click webinar. Thanks for your post!
I should have read this sooner. Good info. I did not know that we could stage an ulcer from unstageable to either a 3 or a 4 after the tissue became visable. Same goes for DTI.
Thank you.
Please, I need clarification: If I have a surgical wound left open to heal by secondary intention and it develops eschar in it is it considered unstageable? I thought we could only stage pressure ulcers.
Hi Jane if u have a surgical wound example abd incision that experienced dehiscence and it has necrotic tissue and left to heal from secondary intention it wouldn’t be stageable. Only wounds caused by pressure should be stageable.