I am a fairly new nurse, and in school we were taught to call openings in the residents’ skin “pressure ulcers” and stage them accordingly. But other nurses are correcting me. They say there are different assessments for wounds. Can you help me with terminology and assessments?
First of all, always follow your facility’s policies and procedures. Upon your orientation, this should have been reviewed with you.
In 2016, The National Pressure Ulcer Advisory Panel (NPUAP) revised the definition and stages of “pressure injury.”
The revised staging system uses the term “injury” instead of “ulcer,” and it denotes stages using Arabic numerals rather than Roman numerals.
Pressure injuries are classified and described through the use of staging systems. You must use the right one.
Only pressure injuries should be staged with the NPUAP Pressure Injury Staging System.
Diabetic foot ulcers use the Wagner Classification System, venous leg ulcers use the Clinical Etiology Anatomy Pathophysiology, skin tears use the International Skin Tear Advisory Panels assessment, adhesive or tape injuries use the Medical Adhesive Related Skin Injury categories (MARS) and burn classifications use total body surface area. It is essential that the intended staging or classification system be used for each type of injury to ensure appropriate treatment.
Since the NPUAP staging system is based on the extent of tissue damage, an understanding of anatomy is essential when evaluating the type of tissue present in the wound.
In addition, NPUAP states, “In order to perform an accurate visual assessment, pressure injury staging should take place only after the wound bed has been cleansed.”