pressure ulcer staging conundrums: a 2 z

9/19/2013

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Pressure Ulcer Staging

Conundrums: A 2 Z

Diane Langemo, PhD, RN, FAAN

Pres. Langemo & Assoc;

Distinguished Prof. Emeritus, U of North Dakota College of Nursing

Pressure Ulcer Staging

Stage/Category I: Nonblanchable Erythema of

Intact Skin

Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. (©NPUAP-EPUAP, 2007)

(©NPUAP, 2008)

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Stage/Category I: Description

The area may be

painful, firm or soft,

warmer or cooler

as compared to

adjacent tissue.

Indicates “at risk”

individuals.

Stage/Category II: Partial thickness skin loss

or blister (©NPUAP, 2008)

Partial thickness loss

of dermis presenting

as a shallow open

ulcer with a red pink

wound bed, without

slough. May also

present as intact or

open/ruptured

serum-filled blister. (©NPUAP-EPUAP, 2007)

(©NPUAP, 2008)

Stage/Category II: Description

Presents as shiny or dry shallow ulcer without slough or bruising. Don’t use II to describe skin tears, tape burns/epidermal stripping, incontinence associated dermatitis, maceration or excoriation. (©NPUAP-EPUAP, 2007)

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Stage/Category III: Full thickness skin loss (©NPUAP-EPUAP, 2007)

Full thickness skin loss.

Subcutaneous fat may

be visible but bone,

tendon or muscle are

not exposed. Some

slough may be present.

May include

undermining and

tunneling. (©NPUAP-EPUAP,

2007)

(©NPUAP, 2008)

Stage/Category III Description

The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of nose, ear, occiput & malleolus don’t have sub-cutaneous tissue & Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep III PU. Bone/tendon is not visible or directly palpable. (©NPUAP-EPUAP, 2007)

Stage/Category IV: Full-thickness Tissue Loss (©NPUAP, 2007)

Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining & tunneling. (©NPUAP-EPUAP,

2007)

(©NPUAP, 2008)

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Stage/Category IV: Description

The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of nose, ear, occiput & malleolus don’t have sub-cutaneous tissue & these PU can be shallow. Stage IV ulcers can extend into muscle &/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis likely to occur. Exposed bone/muscle is visible or directly palpable. (©NPUAP-EPUAP, 2007)

Unstageable Pressure Ulcer:

Description

Full thickness tissue

loss in which actual

depth of the ulcer is

completely obscured

by slough (yellow,

tan, green, gray, or

brown) and/or eschar

(tan, brown or black)

in the wound bed. (©NPUAP-EPUAP, 2007)

(©NPUAP, 2008)

Unstageable Pressure Ulcer:

Description Until enough slough and/or eschar is removed to

expose the base of the wound, the true depth

cannot be determined; but it will be either a

Stage III or IV.

Stable (dry, adherent, intact without erythema or

fluctuance) eschar on the heels serves as “body’s

natural (biological) cover” & should not be

removed. (NPUAP, 2007)

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Unstageable Pressure Ulcer

Unstageable Pressure Ulcer

Suspected Deep Tissue Injury: sDTI

Purple or maroon

localized area of

discolored intact skin

or blood-filled blister

due to damage of

underlying soft tissue

from pressure and/or

shear. (©NPUAP, 2007)

(©NPUAP, 2008)

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Suspected Deep Tissue Injury:

Description The area may be preceded by tissue that is

painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

DTI may be difficult to detect in individuals with dark skin tones.

Evolution may include a thin blister over a dark wound bed. The wound may further evolve & become covered by thin eschar.

Evolution may be rapid exposing additional layers of tissue even with optimal treatment. (NPUAP, 2007)

Suspected Deep Tissue Injury

Photo courtesy of Dr.

Janet Cuddigan

Staging Questions: A

Admission Assessment:

Pt admitted to hospital @

8am, skin assessment done &

documented @9am “No PU

found.” Nurse B does 4pm

shift assessment & documents

“No PU.” Nurse C at

11:30pm finds a Stage II PU. Is

this POA or hospital

acquired?

What is the location?

Can you differentiate it from

MAD?

What about comorbidities?

BP since admission?

Vasopressors?

Immobile?

Conscious?

Turned/repositioned?

Mattress/overlay?

Pt supine or on sides?

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Staging Questions: B

I was told that any areas of breakdown within 1 inch of bony prominence must be classified as a PU. Is this true?

NO!

Areas of nonblanchable redness or breakdown are classified as a PU only when pressure with or w/o shear is/are the main cause(s). Most PUs occur over bony prominences, however arterial, venous, & neuropathic ulcers as well as IAD can occur within 1-2” of a bony prominence.


My patient fell at

home, was admitted

to acute care with a

hematoma/bruise on

the buttocks that got

infected & was

debrided. Is this a PU

or hematoma?

The etiology was the

fall & hematoma,

therefore it is not a

PU unless the patient

was supine

w/pressure to the

area complicating the

situation


Some patients have

diffuse dark reddish

brown discolored skin

over a bony

prominence (fairly

distinct & following the

bony contour) & they

have a PT ulceration

(II). But…what if the

skin is blanchable?

The tissue over and

immediately

surrounding the ulcer

should be

nonblanchable to be a

PU.

Photo courtesy D. Weir

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If a patient had a clear fluid filled blister (II) that ruptured and the base had brown discoloration, would you rename it a sDTI?

Maybe….

A clear, fluid filled blister is PT/II. You would have to determine the etiology of the brown color in the base before you can stage it. Some would stage it II/III & describe the above in the narrative.

Staging Questions: C

What colors are

associated with

pressure ulcer

staging?

RED: nonblanchable

erythema for Stage I

Yellow: slough, not

present in Stage II

Purple/maroon: sDTI

Black/brown: eschar


If a sDTI is

assessed &

documented on

admission to the

agency and within

10 days it opens

up to a Stage IV, is

it still community

acquired?

Yes, it would be a IV.

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I have a patient who

has exposed cartilage

on the nose. Do I

stage this and if so,

how?

The presence of visible

or palpable cartilage in

the base of was recently

addressed by NPUAP.

Cartilage serves the

same anatomical

function as a bone. The

NPUAP position is to

stage it a Stage IV.

NPUAP, 8/27/12

Staging Questions: D

On a sDTI, the

definition includes

“from pressure

and/or shear.” If the

damage appears

to be caused only

by shear, would it

still be considered

a PU?

Yes, it is unlikely that

NO pressure was

involved in the

development of the

PU.

Shear

Pressure Body Weight

Surface

pressure Surface

pressure

Pressure

Shear

Slide courtesy D. Weir

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Staging Questions: D

Why is a DTI a step below Stage I when there is already underlying damage. A blood blister is considered a DTI but a serum filled blister is Stage II. Why is the DTI a step below the fluid filled blister when it is actually worse?

A DTI is not one step below a Stage I. A DTI is a III or IV PU & the NPUAP lists it after Stage IV

Your interpretation is accurate

Staging Questions: E

Scab is the hard coating on skin formed during the reconstruction phase of wound healing, & is comprised of platelets, fibrin & serum. It forms over a Stage II.

Eschar forms on Stage III-IV PUs from the slough. Slough isn’t present in Stage II.


A previously observed PU Stage II now has a scab on it. How do I stage it?

Is this a scab or eschar? Eschar is only present on Stage III-IV PUs, so did it deteriorate to a Stage III?

Eschar on a PU renders it unstageable.

Add additional information in the narrative document to describe what you now see.

http://farm4.static.flickr.com/3164/2722677165_9f95996993.jpg




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A patient has a full- thickness trochanteric ulcer from internal bone calcification that is causing pressure from the inside out. The surgeon said it was unavoidable & would continue to calcify & grow outward from the surgical interventions. Radiology labeled this a “trauma”. Is this a PU or an ulcer from another etiology?

Be a detective.

If the patient was positioned on this area, then pressure was involved, however it arose from an internal pathological alteration to the bony prominence.

It does appear that the MD recognized the unavoidability of this ulcer formation given the altered anatomy & physiology.

PCP documentation is crucial!

Staging Questions: F

A patient is admitted with a Stage III PU that deteriorates to Stage IV. Does this become a Stage IV FAPU?

It is a POA Stage III that evolved or deteriorated to Stage IV. It is important to document on admission that it appears to be in evolution. CMS doesn’t pay for the ulcer care unless it was clear in the initial documentation that it was a PU or DTI in evolution.


My patient had a

surgical flap repair

and this opened

up. How do I stage

it?

OASISanswers.com

says that post flap or

graft, it is always a

surgical wound.

Photo courtesy J. Black

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A patient has a

PU on the

perianal area from

a fecal

incontinence

device. Is this a

PU?

While the etiology is

pressure, the location

is on mucosa and

mucosal PUs are not

staged. It is a PU.


How do you stage a PU when skin failure is involved?

ONLY a PU IF pressure &/or shear involved.

Stage it as you see it.

In the narrative, describe what you see, the suspected etiology, & pathophysiology & labs to back it up.

Most helpful & appropriate for PCP to do this.

Staging Questions: H

A resident had a Stage IV PU documented as healed. Within 16 days a small superficial area was open. AHRQ defined reopened as prior Stage II or > in same location within 2 wks. A nearby wound clinic considers it reopened if within 30 days. Is this a new facility acquired PU or is it the same ulceration re-opened?

This would be a reopened PU appearing as Stage II over a same-site recently healed Stage IV.

It takes up to 1 year for an ulcer to fully “heal”, regaining up to 70% of its former tensile strength.

Just because an ulcer is “closed” doesn’t mean it’s “healed.”

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Staging Questions: H

A patient develops a PU on the heel from offloading the ball of the foot after toe amputations. Is this a PU or diabetic foot ulcer?

This would have to be an ambulatory patient, therefore the pressure is increased on the ball of the foot. This would be a mixed etiology ulcer, most likely diabetic &/or pressure &/or vascular ulcer.

Staging Questions: I

A patient transferred from ICU to StepDown at 9am. The ICU night nurse documented “No PUs” at 5am. On hand off, the StepDown nurse documented “No PUs.” At 12 MN the StepDown nurse documents a PU. Is this POA? Was it a DTI?

Since it is documented (x3) within 24hr post admit that there was no PU, it is likely FA.

It may be a DTI & if so, would likely be POA.

Check patient comorbidities, position, turn/reposition schedule, time in ER. Had the pt been in OR?


How can I tell the

difference between a

PU on the buttocks and

incontinence associated

maceration/dermatitis?

Do I stage IAD?

IAD overall is superficial,

so depth would not

equate to a Stage III.

There are multiple

lesions w/irregular edges,

you may see some

Candida with it.

No, it is not staged.

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A patient developed ischemic areas of their BKA & AKAs secondary to the post-op ace securement dressing being applied too tightly. This has been staged as either "unstageable or sDTI" & captured as a PU. Would this be viewed as ischemic compromise secondary to a too tightly applied compressive dressing or a pressure ulcer.

This would be viewed as an ischemic injury as a result of the compression bandage being wrapped too tightly and impaired circulation.

Staging Questions: K

How can I tell if I am looking at a Kennedy Terminal Ulcer, skin failure or a PU?

A PU is generally located over a bony prominence & involves pressure.

Pure skin failure can occur anywhere, but is generally on the appendages, buttocks/sacral areas, or occiput.

A KTU is described as a mirror-like, butterfly images on the buttocks on either side of the gluteal fold. It may be a DTI that is associated with skin failure, MOF, pressure.

Staging Questions: L

Can the PU staging system be used for intertriginous dermatitis lesions?

No, it is only for pressure ulcers.

Not to be used for diabetic, venous or arterial ulcers either.

Diabetic: Texas, Wagner

Venous: CEAP, Venous Ulcer Clinical Severity Score.

Arterial: Fontaine Classification for PAD or Rutherford System

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Staging Questions: M

When does a

mattress become

a doormat?

When it’s pressure

redistributing

properties are

damaged/lost.

Staging Questions: M

When

documenting a PU

on MDS 3.0,

should the nurse

document the

actual presenting

stage of the PU or

the current stage

of the PU?

CMS protocol is to

document it at its

current stage.

Staging Questions: N

A diabetic patient with

neuropathy developed a

heel PU. Would this be

a PU caused by

neuropathy? A

diabetic/neuropathic

heel ulcer? A PU?

This would be a ulcer of

mixed origin:

neuropathic/pressure

ulcer if indeed pressure

was involved, otherwise

it would be neuropathic.

If it appears as a sDTI, it

might be dry gangrene.

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Staging Questions: O

My patient had his

unstageable PU

debrided in the OR.

What would be

the correct

classification of

this now?

If it was debrided and

the base is visible and

is into or through

muscle, it would be

Stage IV.

If it was also flapped

or grafted, it would

be a surgical wound.

Staging Questions: P

For a POA

pressure ulcer,

where should it be

documented?

To be documented/

verified by PCP

On the H&P

Progress Notes

Wound care sheets

Nurses Notes

PT notes

Staging Questions: R

If I am looking at a

healing Stage IV for

the first time, but I

don’t know that it

was a Stage IV

before, how can I

not “reverse

stage” it?

Truly a staging

conundrum!

If the patient was

transferred to your

agency, check with the

transferring records &

agency

Ask the

patient/family/SO

Ask the PCP

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My patient had a

clearly defined DTI

from a splint. The

surgeon lanced a

small portion of the

center & debrided

the blood blister.

Would it now be

Stage III? Is this

reportable?

Yes, it would be a

Stage III or IV

depending on depth.

Yes, this is reportable

as a device-related

pressure ulcer.


A Stage IV PU heals,

but reopens several

months later. Is it a

IV regardless of

the current

characteristics?

It’s open

superficially &

100% granular.

The correct

documentation

would be a recurrent

PU over a previously

healed Stage IV PU,

now appearing as a

healing Stage III.

Staging Questions: S

Do you stage a PU

using the healing

status or a healing

status tool as the

guideline?

NO & NO!!

Healing status tools

(PUSH, BWAT) are

only to indicate

healing.

NPUAP position is

that PUs are NEVER

reverse staged. It

would be a healing

Stage IV.

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How can I tell the difference between a Stage II and Stage III PU?

Stage II is partial thickness/superficial and does not have slough or eschar. Fluid filled blister would be II.

Stage III is full thickness, does have slough, & can have eschar. Blood filled blister would be a III-IV.


Can you have a PU develop from shear alone?

If a resident has an area of friction/shear, is it necessarily a Stage II?

What if it isn’t over a bony prominence?

Yes, a PU can develop from shear, however it is highly unlikely that no pressure was involved.

If no pressure was involved, it could be pure friction or shear.

Not all PUs form over a bony prominence


My patient’s heels were offloaded, but she used her heels to push herself up in bed causing a maroon discoloration of a heel. The discoloration & likely tissue damage was caused by shear forces from pushing up in bed rather than prolonged unrelieved pressure. Is the damage from shear or pressure?

This would be a PU from shear, friction & pressure from pushing herself up in bed w/her heels.

The maroon discoloration would be a sDTI, again caused by pressure, friction & shear.

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Staging Questions: T

Can a Stage II PU develop prior to a Stage I PU being seen/assessed?

PU development is an inverse time:pressure relationship…high pressure requires shorter time & lower pressure longer time. It’s possible that the nonblanchable erythema of Stage I was not noted prior to the development of the Stage II open area.


A patient is admitted to LTC from the hospital with a Stage II coccyx PU and it proceeds to a Stage III. How do you document this?

Who “owns” the worsening Stage II?

According to CMS POA for Acute Care, the PU is documented on admission as Stage II community acquired.

The admitting agency (LTC) would “own” the worsening to a Stage III unless this was apparent within 1-2 hr of admission (indicating evolving on transfer).

The origin of the PU would be the transferring agency (hospital).


A PU developed under the tracheotomy flange in an obese patient with a very short neck. The ulcer is part of the stoma/trach site, is directly under the flange and in the shape of the flange. How do I document this?

This would be a mucosal device-related PU.

Mucosal PUs are NOT staged.

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Why does a PU

tunnel rather than

open up on the

surface?

Tunneling is primarily

the result of shearing

forces.

Staging Questions: U

My patient had an unstageable PU that developed slough. Would this now be Stage III?

Unstageable indicates the base of the ulcer is not visible. Therefore until the ulcer base is visible, staging cannot occur. If slough is present, it would be either a III or IV. Don’t call it unstageable until it heals.

Staging Questions: U

We have a patient who developed a PU covered with slough/biofilm, so the base wasn’t visible. We documented it as unstageable. Once it was cleaned of most slough/biofilm, it appears to be very superficial. Could it be Stage II?

Any time slough is present it is at least a Stage III.

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Staging Questions: W

Who can stage a PU?

PCP: MD, NP, PA

RN can stage a PU

In some states, LPN/LVN can assess but generally not Stage a PU. Check state nurse practice act.

PCP/NP/PA need to sign off on the dx & staging of the PU.

Staging Questions: Z

How can I tell if the

white in the ulcer is

epithelialization or

zinc oxide?

ZZZZZZzzzzzzzz

Staging Conundrums

Be a detective:

ask the patient & family about history of

PUs, look for scar tissue, read the history

and physical

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Pressure Ulcer Staging Conundrums

THANK YOU!!!

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pressure ulcer staging conundrums: a 2 z

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