Approach
Physical appearance
All patients should have a comprehensive skin examination at the time of admission and then at regular intervals thereafter. A diagnosis of pressure ulcer is typically obvious when an individual with risk factors develops evidence of skin damage over a bony prominence. Thus, damage is supported by the presence of one of the following:
An area of nonblanchable erythema
Marked localized skin changes
A wound of varying severity on an anatomic site that is known (or suspected) to have previously been exposed to significant unrelieved pressure.
Multiple wounds may occur, often in symmetric patterns (both heels and both buttocks, for example). Sometimes there is evidence of earlier healed wounds in areas at particular risk. Pressure ulcer appearance is typically characterized by the depth of the wound.
Photographs may be taken to document progress of wound healing during a hospital admission.
Pressure ulcer classification
Classification schemes are based on the physical appearance of the wound and the type of tissues affected (even though it may be difficult to determine the extent of the wound accurately prior to debridement). Many different pressure ulcer classification schemes have been described in the literature.[53][54]
The National Pressure Ulcer Advisory Panel (NPUAP) published a revised pressure injury staging system in 2016.[1] The revised NPUAP pressure injury staging system reflects current understanding of the etiology of pressure injuries and clarifies anatomical features present at each stage of injury.
Revised NPUAP pressure injury staging system[1]
Category/grade/stage 1: intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; 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 tunneling 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 tunneling 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 ischemic limb or heels should not be softened or removed.
Deep tissue pressure injury: intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration 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 fecal containment devices.
For the purpose of consistency, stage will be used for description in this topic.
History and risk factors
History-taking should include duration of the ulcer, presence of pain, and symptoms of infection (fever, exudates, odor), as well as information on predisposing risk factors. Risk factors include: immobility, use of nonpressure-relieving support surface, sensory impairment, older age, surgery, intensive care stay, malnourishment, history of previous pressure ulcers, fecal or urinary incontinence, diabetes, and peripheral vascular disease.
Environmental factors
The likelihood of developing pressure damage is greatly influenced by the nature of the surface on which the patient has been sitting or lying. Conventional mattresses, operating tables, carts, and wheelchair support surfaces do not provide adequate protection against pressure damage for patients who are unable to reposition themselves regularly.
An immobile patient who has been placed on an inappropriate mattress is greatly at risk of developing pressure damage, and therefore consideration of these factors can add support to a diagnosis of pressure-induced injury.
Investigations
Diagnostic tests are not used to make the diagnosis of pressure ulcers. Certain tests may help in diagnosing complications of pressure ulcers including wound infection and osteomyelitis.
Complete blood count, inflammatory markers, or MRI may be required to exclude the possibility of osteomyelitis.
In cases of suspected wound infection, wound swab or deep tissue biopsy may rarely be required for confirmation, although wound infection is usually a clinical diagnosis. It should be noted that, while commonly used, wound swabs have not been shown to be useful in the management of potential infected pressure ulcers. Wound swab culture results often reflect colonization and not actual infection. Consequently, guidelines do not recommend routine use of wound swabs.[17]
Particular care should be taken to differentiate pressure ulcers from moisture-associated dermatitis.
Tests to exclude alternative causes
Where a diagnosis of pressure damage is uncertain, as in the case of wounds on the lower legs, tests may be appropriate to exclude diabetes (blood glucose), venous insufficiency, or arterial impairment (vascular assessment).
A dermatologic referral may be appropriate for wounds where there is no clear evidence that the damage was sustained from unrelieved pressure, to exclude the possibility of, for example, pyoderma gangrenosum.
Use of this content is subject to our disclaimer