June 13, 2012

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Pressure ulcer staging

By 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?

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DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

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86 thoughts on “Pressure ulcer staging”

  1. Tara says:

    Nancy –

    I have a patient with a 1x1cm stage III sacral ulcer with 60% slough and no drainage. I want to use santyl. What would be the best dressing to use to cover this area?

  2. Nancy Morgan says:

    @Tara since Santyl has to be changed daily consider a composite dressing here is a link to a pic and a company that supplies these:

    http://www.mpmmedicalinc.com/productdetails.aspx?pin=c.WC.1.p.15

  3. Mary says:

    Hi Nancy, I have a question regarding discoloration. I have several patients who chronically have purplish and dark red bilateral buttocks with no prior history of pressure ulcers. However, these areas are blanching, no areas are non-blanching, even where purple. Is this still considered a SDTI? Is there a term for this discoloration? As of now, I have not classified them as pressure ulcers, but there are discrepancies between the treating doctors and corporate nurses. Help! Thank you!

  4. Laura C. says:

    When a stage III or stage IV pressure ulcer is closing without any complications it presents with granulation tissue. When the ulcer is completely closed, is the tissue now considered epithelial? Our agency has checkoff wound sheets and some nurses are documenting closed with granulation tissue and other closed with epithelial. They were inserviced that these PU only close with granulation tissue and must be closed as such. I was taught once closed the tissue is considered epithelialized, who is correct?

    1. Nancy Morgan says:

      @Laura-quick review-full thickness wound heals like this: fills in with granulation tissue and then once its flush with the wound edges then the epidermal cells will migrate across and cover over with epithelialization.

      So if a st 3 or 4 is covered closed up completely it would of covered with epithelialization. Then the would is healed. So it would be a healed st 3 or a healed st 4.

      Hope that helps.

  5. Mary says:

    Nancy, I have a question regarding skin discoloration. I have several patients who have bilateral dark purple buttocks, and this is chronic discoloration. The areas are blanching, not boggy, and not painful, but there is differences in opinion regarding whether or not this is a SDTI or just pigmentation. Please help! Can you still have a SDTI when the area blanches?

    1. Sarah says:

      If it is blanchable, then it is only discoloration.

  6. Ann Dittus says:

    If you have a pt. admitted with a stage II CAPU and the PU closes during the stay and then two months later reopens, is this considered community acquired reopened or is considered hospital acquired now?

  7. Lisa says:

    On my comprehensive assessment the wounds were assessed by wound nurse & coded as SDTI in evolution, now on my 14 day I see she has changed the wounds to ischemic ulcers per the MD active dx. on progress note. How do I code the wounds now?

  8. Hannah says:

    Nancy,

    My patient is receiving compression bandages for severe Lymphedema and developed a dark purple, non-blanchable area in the crease at the lateral ankle. I believe it to be a SDTI; is there any way to treat this without completely d/c’ing her compression therapy? Some kind of foam padding around the SDTI to offload while still applying the wraps?

    Thank you in advance.

  9. jenell lage says:

    My colleagues were needing NY DTF IT-280 last year and learned about a company that hosts a lot of fillable forms . If others are searching for NY DTF IT-280 too , here’s https://goo.gl/c63VBB.

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