Pressure – Unstagable (Eschar Covered)

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

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

Unstageable (Eschar Covered): Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.[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