Pressure Ulcer

Wound staging is the appropriate way to describe a Pressure Ulcer.

According to National Pressure Ulcer Advisory Panel (NPUAP) Guidelines, stage I pressure ulcers are characterized as described below:

Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.[1]

Before classifying a wound as a pressure wound, great care should be used to establish that there is not another health condition that predisposed the individual to the wound and that would therefore change the wound type.

Many lower extremity wounds of diabetic and arterial origin have been mistaken for pressure ulcers, and if care is not used to establish and understand the conditions driving the wound, then some important components of a comprehensive treatment plan may be overlooked.

In order to appropriately establish wound type and etiology, a thorough wound assessment should be completed as required by state and federal guidelines.

This thorough initial wound assessment or wound reassessment (as a component of a wound status change) is described AHS’ Assessment Guideline. It requires a detailed assessment of the whole patient and their history as well as other factors including duration of the wound, patient’s recollection of the causative factors, complaints of pain, fever, numbness or drainage.

References

• [1] National Pressure Ulcer Advisory Panel. 2007 Updated Pressure Ulcer Staging. http://www.npuap.org/pr2.htm