Ask the treatment expert ... about staging an ulcer

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Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC
Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC

What do you do when staff disagree about the stage of an ulcer?

There are a few ground rules that can aid in resolving this issue.

Begin by determining if you have a wound or ulcer. Not all wounds are pressure ulcers. The “Staging System” relates only to pressure ulcers, so if it is not a pressure ulcer, then do not stage the wound.

Another point of confusion occurs in determining if a pressure ulcer is Stage III or Stage IV. Both Stage III and Stage IV pressure ulcers are full-thickness ulcers, indicating that tissue layers other than skin are involved. Caution in the assessment process is encouraged because staging these pressure ulcers could be difficult.

A Stage III pressure ulcer usually presents within the subcutaneous tissue, also called adipose or fatty tissue. Muscle, tendon or bone is not visible or palpable. The subcutaneous tissue may appear as translucent, skinny, moist and healthy. On the other hand, the subcutaneous tissue can appear as slough. The NPUAP defines slough as “soft, moist devitalized tissue. It may be white, yellow, tan, or green and may be loose or firmly adherent.”

A Stage IV pressure ulcer is also a full-thickness pressure ulcer. Therefore, there is tissue loss in both skin layers and through the subcutaneous tissue. Although slough may be noted within the wound bed of a Stage IV pressure ulcer, muscle involvement along with bone, tendon, fascia and joint capsules are also involved.

An accurate assessment must involve a visual inspection and palpation of the entire wound bed. If tunneling or undermining is evident, a Stage IV pressure ulcer is determined. Muscle tissue damage and palpable or visible involvement of other structures, such as bone or tendon, would be determinative of a Stage IV pressure ulcer.