Pressure Ulcer

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

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

Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is 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