Pressure Ulcer

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

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

Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.[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