Pressure ulcer prevention

Ulcer categories

By: Mölnlycke Health Care, December 8 2011Posted in: Pressure ulcer prevention

To describe the state of a wound, EPUAP and NPUAP1 recommend that pressure ulcers be divided into categories I-IV. A category I may indicate the patient is at risk, while category IV means full thickness tissue loss with exposed bone, tendon or muscle.

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Learn more about pressure ulcer categories

Recently revised international definitions and classification system for pressure ulcers have been released by NPUAP and EPUAP (National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009)1.

  • The wording stage, grade are most commonly historically used. Recently the word category has been introduced in order to avoid the impression that there is always a progression from stage I to IV.
  • On reading literature one may see all words used in an interchangeable manner.
  • It is regarded as incorrect to reverse stage a wound as it heals. For example a stage/category IV should be documented always as such. The use of specific tools to monitor healing should be utilised.
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Category/stage I: Persistent, non-blanchable erythema


Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. A stage I may indicate a patient at risk.

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Category/stage II: Partial thickness skin loss


Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. This should not be used when describing skin tears for example. Be aware that if bruising is present it may indicate deep tissue injury.

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Category/stage III: Full thickness skin loss


Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Be aware that the depth here varies by location for example on an ear where subcutaneous tissue is not present.

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Category/stage IV: Subcutaneous tissue loss


Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Be aware that the depth here varies by location for example on an ear where subcutaneous tissue is not present; stage IV wounds can extend into muscle and supporting structures.

In the USA NPUAP have added two further categories which may be referred to as stage IV in other classification systems such as the one issued by EPUAP.

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Suspected deep tissue injury


Purple or maroon localised area of discoloured intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

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Unstageable


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.

Pressure ulcers are often difficult to diagnose, there has been confusion particularly between pressure ulcers and a wound caused by moisture. It is critical to correctly diagnose as both prevention and treatment programmes may differ2.

Key characteristics to be aware of (adapted from EPUAP statement)2

 Moisture should be present, for example incontinence.
A wound located on a bony prominence is most likely to be a PU, however, this is not an exclusive statement. Moisture lesions can occur on a bony prominence but ensure that pressure and shear have been excluded as causes, and moisture is present.
Surrounding skin that presents with pink/white spots usually points to maceration.
While PU tend to be singular and regular in shape moisture lesions tend to be diffuse with multiple spots and irregular in shape.
Moisture lesions are usually superficial.
If necrosis is present it is unlikely to be a moisture lesions.

References

  1. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009.
  2. Pressure Ulcer Classification; Differentiation between pressure ulcers and moisture lesions. EPUAP Review 6(3); Defloor T., et al; 2005.
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