Knowledge Articles

Ulcer categories

By: Mölnlycke Health Care, April 15 2014Posted in: Knowledge Articles

To describe the state of a wound, EPUAP and NPUAP1 recommend that pressure ulcers be divided into categories 1-4. A category 1 may indicate the patient is at risk, while category 4 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 1 to 4.
  • 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 4 should be documented always as such – the use of specific tools to monitor healing should be utilised.

 

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Category/ Stage 1 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 1 may indicate a patient at risk. 

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Category/ Stage 2 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 is bruising is present it may indicate deep tissue. 

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Category/ Stage 3 Full thickness skin loss.


Stage 3 pressure ulcer 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 4 Subcutaneous tissue loss.


Stage 4 pressure ulcerFull 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 4 in other classification systems such as the one issued by EPUAP.

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Suspected deep tissue injury


Suspected deep tissue injury discoloured intact skin or blood filled blister 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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Unstagable

Unstagable Full thickness tissue loss in which the base of the ulcer is covered by slough 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 differ.21

Key characteristics to be aware of (adapted from EPUAP statement)21

 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. Bibliometric Analysis of Pressure Ulcer research. JWOCN; 37(6); 627-632; Hong-Lin Chen et al; 2010
  3. Medical Device related pressure ulcers in hospitalised patients. International Wound Journal; 7(5); 358-365; Black J M et al; 2010
  4. WOCN Society. Professional Practice Manual 3rd Edition, Appendix D Prevalence and Incidence: A Toolkit for Clinicians, Mt. Laurel NJ; 2005 3. Dressing related pain in patients with chronic wounds: an international patient perspective. Price P et al. International Wound Journal; 2008
  5. International Guidelines: Pressure ulcer prevention: prevalence and incidence in context. A consensus document. London: MEP Ltd, 2009
  6. Pressure Ulcer Prevalence Monitoring Project: Summary report on the Prevalence of Pressure Ulcers. EPUAP Review; Volume 4, Issue 2, 2002
  7. Results of nine international pressure ulcer surveys: 1989-2005. Ostomy Wound Management; 54(2). Vangilder C et al; 2008
  8. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy/Wound Management. 50(10):22-38. Woodbury MG, Houghton PE; 2004
  9. Prentice JL, Stacey MC. Pressure ulcers: the case for improving prevention and management in Australian health care settings. Primary Intention 2001; 9: 111-12027
  10. A Cross-sectional Descriptive Study of Pressure Ulcer Prevalence in a Teaching Hospital in China Zhao G, Ostomy Wound Manage. 2010 Feb;56(2):38-42
  11. Factors affecting healing of Pressure ulcers in Korean Acute Hospital. Sung Y.H et al. WOCN January 2011
  12. Description of pressure ulcers pain at rest and at dressing change. Szor JK. JWOCN. 26(3):115–120; 1999
  13. Pressure ulcer pain suffering; issues in a multi centre pain prevalence, Nixon J et al. Oral presentation at EPUAP Annual Conference, Birmingham, UK. 2010
  14. Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 18(4): 137–44 Bales I, Padwojski A ;2009
  15. The cost of pressure ulcers in the UK: Age and Ageing; 33: 230–235; Bennett G et al; 2004
  16. Legal Issues in the Care of Pressure Ulcer Patients: Ket Concepts for Healthcare Providers – A Consensus Paper from the International Expert Wound Care Advisory Panel. 23(11):493-507, November; Fife C et al; 2010
  17. Centers for Medicare & Medicaid Services. Proposed Fiscal Year 2009 Payment, Policy Changes for Inpatient Stays in General Acute Care Hospitals. Available at: http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3045&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500. Accessed May 13, 2008.
  18. Centers for Medicare & Medicaid Services. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding Financial Relationships Between Hospitals and Physicians; Proposed Rule. Federal Register. 2008;73(84):23550. Available at: http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf
  19. Hospitalisation related to pressure ulcers among adults 18 years and over. Agency for Healthcare Research and Quality; Statistical Brief #64. 2006
  20. Interprofessional Management of Complex Continuing Care Patient Admitted with 18 Pressure Ulcers. Baker T et al. Ostomy Wound Management; Feb 2011
  21. Pressure Ulcer Classification; Differentiation between pressure ulcers and moisture lesions. EPUAP Review 6(3); Defloor T., et al ;2005
  22. Wound Dressing Shear Test Method (Bench) Providing Results Equivalent to Humans.Bill B et al. Poster Presentation at the EPUAP Congress, Oporto, 2011
  23. Wound Dressings, Measuring the Microclimate They Create, Call E. Oral Presentationat the EPUAP Congress, Oporto, 2011
  24. Dressings can prevent pressure ulcers :fact or fallacy? The problem of pressure ulcer prevention. Wounds UK;5(4) pg 61-64; Butcher M et al; 2009
  25. Journal of Wound, Ostomy and Continence Nursing: May/June 2007 - Volume 34 - Issue 3S - p S67 doi: 10.1097/01.WON.0000271036.00057.f8 Scientific and Clinical Abstracts From the 39th Annual Wound, Ostomy and Continence Nurses Annual Conference, Salt Lake City, Utah, June 9-13, 2007:Research Abstracts: Wound-Evidence-Based Interventions
  26. Shear A contributory factor in pressure ulceration. A presentation aimed at clinicians and associated professional. www.npuap.org; accessed 14/12/09
  27. Temperature-modulated pressure ulcers: a porcine model. Arch Phys Med Rehabil. 76(7):666-73; Kokate J.Y et al; 1995
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