Pressure ulcer

The National Pressure Ulcer Advisory Panel published a revised pressure injury staging system in 2016.[1]Edsberg LE, Black JM, Goldberg M, et al. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: Revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016 Nov/Dec;43(6):585-97. https://www.doi.org/10.1097/WON.0000000000000281 http://www.ncbi.nlm.nih.gov/pubmed/27749790?tool=bestpractice.com The revised NPUAP pressure injury staging system reflects current understanding of the aetiology of pressure injuries and clarifies anatomical features present at each stage of injury.

Revised National Pressure Ulcer Advisory Panel (NPUAP) pressure injury staging system[1]Edsberg LE, Black JM, Goldberg M, et al. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: Revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016 Nov/Dec;43(6):585-97. https://www.doi.org/10.1097/WON.0000000000000281 http://www.ncbi.nlm.nih.gov/pubmed/27749790?tool=bestpractice.com

• Category/grade/stage 1: intact skin with a localised area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Colour changes do not include purple or maroon discolouration; these may indicate deep tissue pressure injury.

• Category/grade/stage 2: partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissue is not visible. Granulation tissue, slough and eschar, are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.

• Category/grade/stage 3: full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges), is often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunnelling may occur. Fascia, muscle, tendon, ligament, cartilage, or bone is not exposed. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury.

• Category/grade/stage 4: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunnelling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury.

• Unstageable full-thickness pressure injury: full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on ischaemic limb or heels should not be softened or removed.

• Deep tissue pressure injury: intact or non-intact skin with localised area of persistent non-blanchable deep red, maroon, purple discolouration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin colour changes. Discolouration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury.

• Medical device-related pressure injuries: result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

• Mucosal membrane pressure injury: found on mucous membranes with a history of a medical device in use at the location of the injury. Mucosal tissues are especially vulnerable to pressure from medical devices such as oxygen tubing, endotracheal tubes, bite blocks, orogastric and nasogastric tubes, urinary catheters, and faecal containment devices.

For the purpose of consistency, stage will be used for description in this topic.