Pressure Injuries - An Update

Clinical Corner ran a series on skin protection and seating in 2011. Since that time, revised Clinical Practice Guidelines related to pressure injuries have been published. This month, Clinical Corner will review some of the updated terms and information related to pressure injuries and their staging.

Change in Terminology

One of the changes that has taken place is in the terminology that is used to describe what was once called a "pressure ulcer". The National Pressure Ulcer Advisory Panel (NPUAP) has replaced the term "pressure ulcer" with "pressure injury" (NPUAP, 2016). Let's look at the reason for the change in language and the revised definition of a pressure injury.

When we consider the word "ulcer", it implies an open wound. Miriam-Webster's online dictionary defines an ulcer as "a break in skin or mucous membrane with loss of surface tissue, disintegration and necrosis of epithelial tissue, and often pus" (2019). The definition of an ulcer did not correspond with some of the staging of pressure injuries as Stage 1 pressure injuries and Deep Tissue pressure injuries involve intact skin. According to the NPUAP, "The change in terminology more accurately describes pressure injuries to both intact and ulcerated skin. In the previous staging systems 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'." (2016, 1^st paragraph).

The NPUAP defined a pressure injury: "A pressure injury is 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 in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue." (2016, 6^th paragraph).

Changes to Staging of Pressure Injuries

There have been some changes to the naming conventions of staging pressure injuries. In the past, Roman Numerals were used to identify the stage of the pressure injury. Now, regular numbers are used (i.e., 1, 2, 3, 4). In addition, the word "suspected" has been removed when classifying a Deep Tissue Injury (NPUAP, 2016).

Let's review the stages of pressure injury.

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

This stage may include changes in sensation, temperature or firmness before there are any changes observed on the skin.

Stage 2 Pressure Injury: Partial-thickness skin less with exposed dermis

According to the NPUAP, "these injuries commonly result from adverse microclimate and shear 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 dermatitis (ITD), medical adhesive related skin injury (MARSI) or traumatic wounds (skin tears, burns, abrasions)" (2016, 8^th paragraph).

Stage 3 Pressure Injury: Full-thickness skin and tissue loss

The depth of the tissue loss will vary by anatomical location and amount of adipose tissue. If the extent of the tissue loss cannot be determined due to slough, the injury is an Unstageable Pressure Injury.

Stage 4 Pressure Injury: Full-thickness skin and tissue loss

Fascia, muscle, tendon, ligament, cartilage or bone will be palpable or observable. If the extent of the tissue loss cannot be determined due to slough, the injury is an Unstageable Pressure Injury.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss

If the slough or eschar is removed, a Stage 3 or Stage 4 pressure injury would be revealed.

Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discolouration

Pain and temperature change often occur prior to changes in the 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 underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4)." (NPUAP, 2016, 12^th paragraph).

Now, let's look at some of the clarifications that the NPUAP provided regarding staging of pressure injuries. The NPUAP provided the following position statements:

• Position Statement 1: The diagnosis of a 'pressure injury' does not mean that the health care provider(s) 'caused' the injury.
• Position Statement 2: Some pressure injuries are unavoidable despite provision of evidence-based care by the health care team.
• Position Statement 3: The numerical staging system does NOT imply linear progression of pressure injuries from Stage 1 through Stage 4, nor does it imply healing from Stage 4 through to Stage 1.
• Position Statement 4: The NPUAP Staging System classifies pressure injuries based on the type of tissue loss that can be visualized or directly palpated.
• Position Statement 5: The pressure injury may be more extensive than initially apparent. The wound base and surrounding tissue should be assessed for variations in sensation, temperature, firmness, color and any expression of drainage from surrounding tissues when palpated.
• Position Statement 6: Deep Tissue Pressure Injury (DTPI) may evolve into a full thickness wound despite optimal care.
• Position Statement 7: Any pressure injury should be treated in accordance with current evidence-based practices and monitored closely for changes that require re-evaluation of treatment strategies. (NPUAP, 2017, p. 2-5).

Summary

This month, Clinical Corner has reviewed the updated terminology used for pressure injuries and the staging of pressure injuries. In addition, the position statements of the NPUAP related to pressure injuries have been reviewed. More information on Pressure Injuries can be found on the NPUAP website.

References

1. NPUAP. (2016). National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. Retrieved from http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/
2. NPUAP. (2017). NPUAP Position Statement on Staging – 2017 Clarifications. Retrieved from https://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Position-Statement-on-Staging-Jan-2017.pdf
3. Ulcer. 2019. In Merriam-Webster.com. Retrieved from https://www.merriam-webster.com/dictionary/ulcer