FAQs for pressure ulcer staging - Wound Care Advisor

FAQs for pressureulcer stagingBy Donna Sardina, RN, MHA, WCC, CWCMS,DWC, OMSStaging pressure ulcers can be challenging.Below are some commonquestions—and answers—aboutstaging.QIf a pressure ulcer heals (completelyepithelialized over), but later reopensat the same site, how should it be staged?AAccording to the National PressureUlcer Advisory Panel, if a pressureulcer reopens in the same site, the ulcershould be listed at the previous stagingdiagnosis (for example, if it was a Stage IVbefore it closed, it would be a Stage IVwhen it reopened). 1Remember that pressure ulcers heal to aprogressively more shallow depth. Theydon’t replace lost muscle, subcutaneous fat,or dermis before they reepithelialize. Instead,the full-thickness ulcer is filled withscar tissue composed primarily of endothelialcells, fibroblasts, collagen, and extracellularmatrix. A Stage IV pressure ulcer,therefore, can’t become a Stage III, StageII, or subsequently Stage I pressure ulcer. 1QCan pressure ulcer staging be usedfor venous ulcers?ANo. The National Pressure Ulcer AdvisoryPanel and European PressureUlcer Advisory Panel state that a pressureulcer classification system can’t be used todescribe tissue loss in wounds other thanpressure ulcers. 2QIfa wound first presents as a suspecteddeep-tissue injury (SDTI) and thenbecomes open, should I chart it as a healingSDTI or restage it as it presents?AStaging is based on the deepest levelof tissue destruction through the layersof skin; therefore, you stage accordingto what level of destruction you seeand/or feel. So, as the ulcer changes characteristics,you should restage it basedupon what you see.Remember to refer back to the definitionsfor each stage, and if you can’t tellwhat you are looking at, document thewound as unstageable.QOnce a pressure ulcer is debrided,does it become a surgical wound andno longer need staging?AAccording to the Centers forMedicare & Medicaid Services (CMS),a pressure ulcer that has been surgicallydebrided remains a pressure ulcer, andisn’t considered a surgical wound. 3,4QWhat would be the new stage for aStage II pressure ulcer that developsslough?ABecause staging is based on thedeepest level of tissue destructionthrough the layers of skin, you wouldstage the ulcer according to the level ofdestruction you see and/or feel.If the Stage II ulcer is covered in sloughto the extent you can’t see or palpate thedeepest level of tissue destruction, itwould be considered unstageable. However,if there is scattered, superficial sloughand the deepest level of tissue destructioncan be seen or palpated, then the ulcerwould be either a Stage III or Stage IV.QIf a Stage IV pressure ulcer is repairedwith a surgical flap, would it still be aStage IV or would it be unstageable?14 www.WoundCareAdvisor.com November/December 2012 • Volume 1, Number 4 • Wound Care Advisor

Stages of pressure ulcersSuspected deep tissue injuryStage 1Stage 2Stage 3Stage 4UnstageableAAccording to the CMS, if a muscleflap, skin advancement flap, or rotationalflap is performed to surgically replacea pressure ulcer, the area is considereda surgical wound and is no longer apressure ulcer. If the flap fails, continueto code the area as a surgical wound untilit’s healed. 3,4QCan a wound have two stages? My patienthas a Stage III pressure ulcer, butI also see dark purple around part of it.Should I document it as Stage III with suspecteddeep-tissue injury?AA wound can’t have two stages. Theentire pressure ulcer should bestaged based upon the deepest level of tissuedestruction in the ulcer, so in this casethe wound would be considered Stage III.A Stage III depth is deeper than a suspecteddeep-tissue injury.QI know that friction and shearing contributeto pressure ulcer developmentbut when do I stage it? For example, a patient’selbow has rubbed across the surface ofthe bed, resulting in missing epidermis. Is thisnow an abrasion or a Stage II pressure ulcer?AThe situation you describe would bean abrasion.It’s worthwhile to consider the role offriction and pressure ulcers. Friction forceoccurs when two objects rub against eachother. Friction isn’t a direct cause of pressureulcers, but can contribute to shearstresses in skin and in deeper tissue layers,which, in combination with pressure, resultsin pressure ulcers. 5Wound Care Advisor • November/December 2012 • Volume 1, Number 4 www.WoundCareAdvisor.com 15

QCan a patient have a friction woundwithout pressure?AFriction force occurs when two objectsrub against each other. According toHanson and colleagues, “Friction abradesthe skin of the epidermis and dermis, therebydecreasing the amount of pressure neededto create a pressure ulcer.” 6QCan a patient have a shearing woundwithout pressure?AYes, but it’s rare. Pressure on soft tissues,especially when over a bonyprominence, will cause some degree ofshear through tissue distortion. 2,5 Shearstresses arise from forces applied tangentiallyto a surface and cause deformationof the object involved. Shear stresses usuallyoccur in combination with pressure. 5QA patient’s waistband dug into hisside and caused skin breakdown. Isthis considered a pressure ulcer?AYes. Pressure along with friction fromthe constriction of the waistband ismost likely the cause of the skin breakdown,and this would be considered apressure ulcer.QA patient has a cast or device removedand there is skin breakdownunderneath. Is this a pressure ulcer?AYes, this would be considered a pressureulcer and would need to bestaged according to depth of the tissuedestruction.QMy patient has a pressure ulcer that is100% filled with slough, and I’ve determinedit’s unstageable. In addition todocumenting length and width, should Ialso try to determine a depth? Can youtechnically have a depth that is 0.1 cm?AIt can be difficult to measure depth insuperficial partial-thickness ulcers orwounds covered with slough. If the depthis less than 1 mm, document as “< 0.1 cm.” 7Keep in mind that if a wound is open,it will have depth, because at least theepidermis has been penetrated. The epidermishas a thickness of 0.1 to 0.6 mm,and the dermis thickness can range from 2to 4 mm.■Resources• National Pressure Ulcer Advisory Panel.NPUAP pressure ulcer stages/categories.• Pressure ulcer staging test. Practice yourskills.References1. National Pressure Ulcer Advisory Panel. The factsabout reverse staging in 2000. The NPUAP PositionStatement. http://www.npuap.org/wp-content/uploads/2012/01/Reverse-Staging-Position-Statement%E2%80%A8.pdf. Accessed November 1, 2012.2. National Pressure Ulcer Advisory Panel and EuropeanPressure Ulcer Advisory Panel. Prevention andtreatment of pressure ulcers: clinical practice guideline.Washington, DC: National Pressure Ulcer AdvisoryPanel; 2009.3. Centers for Medicare & Medicaid Services. OASIS-CGuidance Manual September 2009 for 2010 ImplementationChapter 3: F-1. vnaa.org/vnaa/g/?H=HTML/doc/OASIS-C_ItemGuidance.pdf. Accessed November1, 2012.4. Centers for Medicare & Medicaid Services. RAIVersion 3.0 Manual. Section M. October 2011.5. International Review. Pressure ulcer prevention:pressure, shear, friction and microclimate in context.A consensus document. London: Wounds International;2010.6. Hanson D, Langemo DK, Anderson J, ThompsonP, Hunter S. Friction and shear considerations inpressure ulcer development. Adv Skin Wound Care.2010 Jan;23(1):21-4.7. Hess CT. Clinical Guide to Skin and Wound Care.7th ed. Philadelphia, PA: Lippincott Williams &Wilkins; 2012;chap 2.Donna Sardina is Editor-in-Chief of Wound CareAdvisor and cofounder of the Wound Care EducationInstitute in Plainfield, Illinois.16 www.WoundCareAdvisor.com November/December 2012 • Volume 1, Number 4 • Wound Care Advisor