Accurate documentation and treatment of pressure ulcers protects and maximizes outcomes for the patient, caregiver, and facility.

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our shift starts, you receive a report, you begin to make rounds, and—lo and behold— you get a new admission. The patient arrives to your unit, and you need to do a full assessment immediately. Knowing that a pressure ulcer can occur in less than 2 hours, you decide to start with the skin assessment.
       The new resident is an elderly woman with poor skin turgor who appears cachectic. She is not oriented, so obtaining an oral history is not possible. You begin to assess her skin for any breakdown. When you turn her over, you note that she has a few different ulcers. None of them looks the same. Some are open. Some are still closed but reddened. Some are so deep that you can see bone. Where do you start? How do you stage all of these different wounds? Do not worry—there is a system. When you accurately document, it protects you, your facility, and the patient. Want to learn more? Let us get started.

Definitions and Assessment

       First, let us define what a pressure ulcer is and how it develops. Pressure-related injury develops with 3 types of forces: pressure, shear, and/or friction. Pressure insult occurs when tissue is compressed between a bony prominence and an immobile surface like a bed. The consequence of unrelieved pressure is ischemia (ie, lack of blood flow) that causes tissue death and can then form a pressure ulcer. Unrelieved pressure for more than 2 hours can cause pressure ulcers in sites with poor mobility.¹
       You know from experience that the best approach to assessment is to go from the patient’s head to his or her toes. The first wound you encounter is a reddened area on the scapula. You remember that wounds should always be measured from head to toe (length) and side to side (width). The wound is photographed and measured. Now it is time to stage it, if it is indeed a pressure ulcer. You notice that the skin is intact and that there are no openings. The area is reddened. You try to blanche the tissue or gently compress the tissue to check for color change, which is what you want to see. No change in color is seen, so the wound is considered a stage 1. The National Pressure Ulcer Advisory Panel (NPUAP) classifies a stage 1 ulcer as, “an observable pressure-related alteration of intact skin whose indicators, as compared with the adjacent or opposite area on the body, may include changes in 1 or more of following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensations (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin; whereas, in darker skin tones, the ulcer may appear with persistent red, blue, or purple tones.”²
       So, your patient has a stage 1 ulcer on her scapula. After finishing the assessment of all the wounds, you will need to go back and address such issues as nutrition, support surfaces, the need for any debridement of dead tissue, and pain management for not only this ulcer but all the ulcers. Each will have its own care plan.
       Now you look at your patient’s elbow. She has a blister present. The blister is intact and appears to have clear fluid inside. How do you stage this ulcer? It is not intact skin but not a deep ulcer. Again, you turn to the NPUAP guidelines for direction and realize that the blister will be classified as a stage 2 pressure ulcer. The NPUAP definition for stage 2: “Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.”²
       Moving along, you get to the patient’s hip. There you find a large ulcer, extending into the subcutaneous level or fatty tissue of her skin. It is yellow, fibrous material in the middle of the wound. There is also what appears to be a lip of tissue around the wound that is not attached. You can stick a cotton swab under the lip and measure its depth (ie, undermining). It is tissue destruction that has happened underneath the skin. This also must be measured and documented. What stage would this be? There is deeper tissue destruction. There is undermining and yellow fibrous material (also known as slough) present in the wound base. If we go back to the NPUAP treatment manual, we will see that this wound would be classified as a stage 3. The definition: “Full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.”²
       The next assessment stop is her right heel. You notice that she has a large ulcer encompassing most of the heel. You can see the calcaneous bone; there is muscle and tendon exposure. There is a tunnel on the left side of the wound that measures 4 cm in depth. You remember that you need to measure length x width x depth and then measure any tunneling or undermining. The measurement that was obtained for the tunneled depth should not be considered the depth of the wound. This wound is a stage 4 pressure ulcer. The NPUAP definition of a stage 4 ulcer: “Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure (example: tendon or joint capsule).” Undermining and sinus tracts also may be associated with stage 4 pressure ulcers.²
       You notice there is a large area of black eschar on the patient’s left heel. There is no granular tissue or yellow fibrous tissue noted. The entire area is black, hardened, and necrotic. If you were to follow the NPUAP manual, you could not stage this ulcer. How do you know what tissue destruction lies underneath? Unless you hold a crystal ball, you do not. In long-term care, the federal regulations state that you must classify this as a stage 4 pressure ulcer. While this may not be correct, given the current best practices for assessment, it is what is mandated. If this area of eschar is boggy or foul-smelling, it must be addressed immediately; an active, infectious process may be occurring underneath.
       Now that you have all of these data, what do you do with them? Your documentation needs to encompass stage, length, width, depth, any undermining, tunneling, slough, eschar, color of drainage, any pain present, whether any odor exists, and whether there is exposure to any underlying structures (eg, bone, tendon, or muscle). How are the wound edges? Are they reddened, excoriated, macerated, pigmented, or normal? Another practitioner who reads your note should be able to envision the wound through your documentation without ever seeing the wound.

Is it a Pressure Wound?

       Before staging, the first thing that needs to be done is to figure out the cause or etiology of the wound. Is it a venous stasis ulcer, a diabetic ulcer, an arterial ulcer, a traumatic ulcer, or a pressure ulcer? A frequently occurring mistake is when clinicians stage wounds that are not pressure ulcers. For example, some wounds that occur because of venous stasis disease should not be staged. Venous ulcers should be classified as superficial, partial-thickness, or full-thickness. Diabetic foot ulcers should not be classified as pressure ulcers; they have their own scale (the Wagner scale) to identify the level of destruction.³ This is why it is very important to know the etiology behind why the wound occurred. This will help the clinician make an appropriate diagnosis and plan of care.
       One caveat to consider in long-term care is that, according to the Minimum Data Set (MDS), all wounds need to be staged—no matter the etiology. This flies in the face of current best practices for assessing and documenting, but it is a requirement in order to obtain federal funding. In addition, a wound that presents as a black eschar must be staged as a stage 4, according to the MDS.

Assessing Pain

       Have you assessed your patient for pain? Pressure ulcers can be extremely painful.⁴ Assess your patient for pain quality and address the issue with the healthcare team. Perhaps the patient only has pain during dressing changes; if so, an order should be written to have the patient pre-medicated prior to dressing changes to ease any pain associated with that treatment. The patient should be reassessed frequently to ensure that the modalities being used for pain management are adequate. Special dressings that are atraumatic (eg, soft silicones, polyacrylates, amorphous hydrogels, and hydrofibers) can decrease pain at dressing change.⁴

Deep Tissue Injury

       An area that has been getting attention lately is the

Sidebar

topic of deep

Figure 1

An example of deep-tissue injury (DTI).

tissue injury (DTI). (See Figure 1 for an example of DTI.) When we look at a patient and classify him or her as having a stage 1 pressure ulcer, how do we know what is really going on underneath that intact skin? Does the injury involve just the first few layers of skin, or does it go much deeper? Will a full-thickness wound evolve because of the tissue destruction that has already occurred? (See the sidebar article, above, for more information about DTI).

Nutrition

       Has someone evaluated the patient’s nutritional status? If not, key questions to ask include:
• Is the patient overweight or underweight, or has he or she recently lost or gained a large amount of weight?
• Does he or she have any medical conditions (eg, diabetes) that would further impair wound healing?
• Is he or she on any medications known to inhibit wound healing or have metabolic effects?
• Has he or she recently sustained an immobilizing fracture that will need certain nutrients to help facilitate healing?
• Have labs been drawn to assess albumin and prealbumin levels?
       If the prealbumin level is low, it must be addressed. When looking at prealbumin levels, use the “rule of 5s.” Greater than 15 mg/dL is normal, less than 15mg/dL is a mild deficiency, less than 10mg/dL is a moderate deficiency, and less than 5mg/dL is a severe deficiency.⁸ If the patient is in a catabolic state, the type of wound care provided will not matter much because the body does not have the ability to utilize protein to help heal the wounds. Today, there are several modalities on the market designed to help improve albumin and prealbumin levels to facilitate wound healing. They can be found in the form of pharmaceuticals and nutrition, vitamin, and mineral supplements.

Support Surfaces

       Have you evaluated which type of mattress or seat cushion your patient is on? If he or she is at risk for development of pressure ulcers or has an existing pressure ulcer, the patient should not be placed on a regular hospital mattress. The care plan should reflect various levels of support surfaces, chosen based on the client’s needs. There are many redistribution mattresses, overlays, beds, cushions, and off-loading devices on the market. The preference will depend on which type of surfaces your facility offers and the patient’s pressure ulcer risk and status.

Reverse Staging

       Currently, federal regulations require long-term care facilities to reverse stage. This can make the process very confusing, since staging ulcers is the classification of anatomical tissue destruction. When a wound heals, those structures (eg, bone or tendon in a stage 4 wound) do not regenerate. Instead, scar tissue forms and fills the defect. That is why reverse staging is not considered the current best practice. Despite the care setting, always document appropriate healing using either descriptive characteristics of the wound (eg, length, width and depth, granulation tissue, necrotic tissue, etc.) or a validated pressure ulcer healing tool. In other words, once a stage 4, always a stage 4. If a pressure ulcer heals and then reopens in the same anatomical site, the ulcer resumes the previous stage.⁹
       If a patient develops a stage 4 pressure ulcer with muscle destruction, he or she will not have regrown muscle in that area when it is resolved. The wound will be filled with scar tissue that now only has about 80% of its original tensile strength.¹⁰ This is why it should not be called a stage 3; no new muscle layer has grown in that wound, and there is now a layer of scar tissue.

Risk Assessment Tools

       Facilities usually employ one of several different risk assessment tools for prevention of pressure ulcers. Two that you may be familiar with include the Braden Scale (available at www.bradenscale.com/ braden.PDF) and the Norton (or Norton Plus) Scale. These tools help determine whether your patient is at risk for developing an ulcer. They take into account such factors as the patient’s mental status, mobility, nutrition, and moisture. They are numerical scales that address different categories to determine whether the patient is at risk for breakdown. The Braden Scale has a threshold for risk of 18, for instance.¹¹ By identifying the risk early on, the practitioner can implement protocols and procedures to help reduce the risk of the patient developing skin breakdown. Such modalities include the incorporation of nutritional and/or vitamin/mineral supplements, different support surfaces, more frequent turning and repositioning, and the utilization of different continence products.

Healing Tool

       The Pressure Ulcer Scale for Healing (PUSH) Tool is a document that was developed by the NPUAP as a quick, reliable tool to monitor the change in pressure ulcer status over time. PUSH looks at length x width (scored from 0–10), exudate amount (scored from 0/none–3/heavy), and tissue type (scored from 0/closed–4/necrotic tissue) in the wound and tracks it along a time line. The PUSH Tool is a research-validated tool that quickly and reliably captures the key assessments necessary to monitor whether a pressure ulcer is getting better or worse over time.¹² (The PUSH Tool version 3.0 is available at www.npuap.org.)

A “New” Stage 1

       Back in 1998, the NPUAP convened a task force to review the definition of stage 1 pressure ulcers and determine the adequacy of the definition in assessing individuals with darkly pigmented skin tones. The definition was augmented to reflect a comprehensive review of the literature and peer review. The current definition of a stage 1 pressure ulcer is, “an observable pressure-related alteration of intact skin whose indicators as compared to the adjacent or opposite area of the body may include changes in 1 or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, it may appear with persistent red, blue, or purple hues.”¹³

Wounds in Various Stages

       To follow are several case studies that address different wounds in various stages (see the photographs to the right) as well as the associated treatment modalities.

Wounds in Various Stages

Stage 1 Pressure Ulcer

       Mr. S. is a 75-year-old long-term care resident. He recently suffered a cerebral vascular accident (CVA) resulting in left hemiparesis. His skin is intact on his last assessment; his Braden score, post-CVA, is noted to be a 13. You notice that his left heel is reddened. This could be the result of his hemiplegia. The best course of action at this time would be to elevate his heel off the bed using something as sophisticated as a device that will keep his heel off the bed or something as simple as a pillow or rolled up blanket placed under his shin to elevate his heel off of the bed. This heel, along with the rest of his skin, will need to be watched very closely to ensure that the stage 1 does not progress. Frequent monitoring and moisturizing may prevent the stage 1 from worsening.

Stage 2 Pressure Ulcer

       Ms. B. is a 48-year-old resident who has advanced multiple sclerosis (MS). She has been unable to ambulate for the past 2 months. On your daily assessment you note that she has developed a stage 2 to her left buttock, specifically the ischial tuberosity. It measures 1 cm x 1 cm x 0.1 cm and has no foul odor or slough tissue, and there is no undermining or tunneling noted. You obtain an order to cleanse the wound with a wound cleanser and apply a hydrocolloid dressing to the area. The hydrocolloid will protect the wound as it begins to heal. The hydrocolloid should be changed every 3 days. Since this is not a deep wound, a low-profile hydrocolloid would be sufficient. A strict turning schedule is put in place to help offload the area as much as possible to reduce pressure and allow for wound healing. The patient’s support surface, both for chair and bed, was also addressed.

Stage 3 Pressure Ulcer

       Mr. B. is a 64 year-old resident who has developed a stage 3 ulcer to his right heel. It measures 2 cm x 1 cm x 0.2 cm. Tissue destruction is noted down into the subcutaneous layer. There is yellow slough noted to the base and a slight foul odor. There is undermining that measures 2 cm around the entire wound. The wound has a large amount of serous drainage, which is macerating the periwound skin. What do you need to do first? You have identified that the wound is heavily exudating; this will call for the use of an absorptive dressing like an alginate. An alginate rope may be appropriate in this wound because you can lightly pack the undermined area, which will aid in the absorption of the excess drainage. The base of the wound has been noted to have slough. That will need to be removed, but how?
       There are several ways it can be removed, such as by debridement by a qualified professional, enzymatic debridement, autolytic debridement, or polyacrylate debridement. With enzymatic debridement, a pharmaceutical cream that requires a prescription is placed on the slough, and enzymes in the cream dissolve the protein in the slough, producing a clean wound base. Polyacrylate debridement is a simple method of removing devitalized material from the wound bed using a pillow-like dressing that is activated with Ringer’s solution and a pad that likes to hang on to dead tissue. Over a 24-hour period, the Ringer’s solution enters the wound bed to begin irrigating and cleaning it up. In turn, the necrotic tissue is washed up into the polyacrylate pad and trapped there. You do not need a prescription to utilize this dressing, and any caregiver can apply it. Also, polyacrylate therapy debrides at the same mean rate as the more expensive, prescription products.¹⁴ Polyacrylate therapy has also been shown to be effective against biofilm (a slimy coating that can be a silent roadblock to healing many chronic wounds).¹⁵ The wound will not be able to heal over the area of slough, so it must be removed. Additionally, any dead tissue provides a breeding ground for infection.
       Once the slough is removed and the amount of drainage assessed, a decision can be made about how to proceed. The periwound skin should also be addressed. It is important for this skin to stay healthy or the wound will deteriorate and become larger. In this case, a zinc oxide cream was placed around the periwound skin to protect it from the copious drainage. If the wound drainage slows, an amorphous hydrogel dressing may be applied. If the wound remains highly exudative, continue with alginate dressings or a similar product that absorbs fluid. The patient was fitted with a device to help offload his foot from the bed and taken to reduce pressure to his heel while sitting in a chair.

Stage 4 Pressure Ulcer

       Ms. G is a 89-year-old resident who was admitted with a stage 4 pressure ulcer to her right trochanter (hip). It measures 8 cm x 9 cm x 5 cm, there is tunneling at 2 o’clock (measuring 6 cm), and there is undermining from 2 o’clock to 8 o’clock (measuring 4 cm). There is full bone and muscle exposure. A heavy, foul-smelling drainage is noted, and the periwound skin to the distal part of the wound is deteriorating due to the large amount of effluent.
       This wound was cleansed with a noncytotoxic, nonionic wound cleanser, patted dry, and gently filled with a silver alginate. There was no slough, so there was not a need for any type of debridement adjuncts. But there was a foul odor, which was possibly caused by heavy bioburden—thus, the need for a silver-based product. The silver alginate kills the bacteria at the level of the wound and soaks up the excess drainage to provide an optimal, moist wound environment that is conducive to wound healing. A nutritional skin cream containing olive oil and zinc oxide was applied to the periwound area to help avoid tissue deterioration in that area.

Conclusion

       There is much to think about when assessing and treating pressure ulcers. It has been said a million times but still remains true that you need to address the whole person, not just the hole in the person. The entire picture (ie, nutrition, pain assessment, support surfaces, mobility, continence, bioburden, and mentation) must come into view. Healthcare practitioners must work as a team to obtain the optimal results. Identifying potential problems before they become tribulations benefits everyone, especially the patient.
       In the past few years, the topic of pressure ulcers has become a buzzword in our litigious society. Millions of dollars are paid out each year to families who have had the misfortune of dealing with a pressure sore. Healthcare workers need to be diligent with their protocols, prevention tools, and documentation to protect all involved, as every pressure ulcer is a potential suit. Comprehensive charting, both written and photographic, is paramount when documenting pressure ulcers. There are many tools available to help the practitioner not only identify potential problems but deal with the problems that exist. Incorporating these modalities into your routine will benefit the patient, facility, and practitioner.