Pressure Ulcer

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

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

Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury.[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