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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?

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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