Goodbye ulcer, hello injury

Bardia Anvar
Bardia Anvar

The National Pressure Ulcer Advisory Panel, which serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research, has said farewell to the term “pressure ulcer.”  Instead, the organization wants the industry to use “pressure injury” instead.  

The change in terminology is meant to more accurately describe pressure injuries. In the previous staging system Stage 1 and Deep Tissue Injury described injured intact skin, while the other stages described open ulcers. This led to confusion because the definitions for each of the stages referred to the injuries as “pressure ulcers.”

The organization began by defining a pressure injury as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure combined with a tear.

To clarify the four stages of pressure injuries:

  • Stage 1 Pressure Injury: Non-blanchable erythema (superficial reddening of intact skin) -- Intact skin with a localized area of non-blanchable erythema 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; they may indicate a deep tissue pressure injury instead.
  • Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis – Here, the wound bed is viable, pink/red, moist and may also present as an intact or ruptured serum-filled blister. Neither fat nor deeper tissues are visible. Granulation tissue, slough and scabbing are not present. These injuries commonly result from adverse microclimate and tears in the skin over the pelvis and shear in the heel.  This stage should not be used to describe moisture-associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous (skin-on-skin) dermatitis (ITD), medical adhesive-related skin injury (MARSI) or traumatic wounds (i.e., skin tears, burns, abrasions).
  • Stage 3 Pressure Injury: Full-thickness skin loss
    Full-thickness loss of skin in which fat is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or scabbing may be visible. The depth of tissue damage varies by anatomical location and areas of significant fat can develop deep wounds.  Undermining and tunneling may occur. Also, fascia, muscle, tendon, ligament cartilage and/or bone are not exposed. If slough or scabbing obscures the extent of tissue loss, this is referred to as an Unstageable Pressure Injury.
  • Stage 4 Pressure Injury: Full-thickness skin and tissue loss -- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage and/or bone in the ulcer. Slough or scabbing may be visible. Epibole (rolled edges) and tunneling may occur. Depth varies by anatomical location. Just as in Stage 3, if slough or scabbing obscures the extent of tissue loss, this is referred to as an Unstageable Pressure Injury.

Two other clarifications were given:

  • Unstageable Pressure Injury (UPI): Obscured full-thickness skin and tissue loss -- 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 scabbing.  If slough or scabbing is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without reddening or abscess) on the heel or limb adversely impacted by restricted blood flow should not be softened or removed.

  •  Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration -- Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or separation of the top layer of skin 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 (Unstageable Stage 3 or Stage 4).  DTPI is not to be used to describe vascular, traumatic, neuropathic or dermatologic conditions.

Board-certified general surgeon Bardia Anvar, M.D. is medical director of Skilled Wound Care, which services nursing facilities, patients and health plans throughout the United States for wound care.  

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