The National Pressure Ulcer Advisory Panel defined pressure injuries as confined damage to the dermis and underlying soft tissue, typically related to a medical device or located above a bony prominence. Essentially, these wounds are caused by sustained or violent force upon the area. These injuries can be affected by patient nutrition as well as microclimate and the overall status of the soft tissue.
Traditionally, there have been four levels for classifying pressure wounds. Emergency Live, however, stated that two new classifications have been added in recent years. Unstageable pressure wounds and suspected deep tissue injuries are for severe skin wounds that need to be treated appropriately to ensure that no long term damage occurs.
The four traditional levels of pressure wounds
The four stages of pressure wounds are designed to track injury intensity. In the first stage, the skin itself is still intact. Localized area of non-blanchable erythema, essentially red patches, appear and the skin’s temperature in this area may be different than elsewhere. While the color of the skin is expected to change, it cannot become purple. Should this occur, it is indicative of a suspected deep tissue injury.
In stage two, the skin has been damaged and the dermis partially exposed. The injury should appear red or pink and feature increased moisture, culminating occasionally in the appearance of a blister. No deeper tissues should be visible. In the past, this condition was sometimes confused with moisture associated skin damage but the two are not linked.
Stage three features full-thickness skin loss. Fat tissue can often be seen in the granulation tissue, ulcer and rolled wound edges. The extent of the tissue damage typically depends on the wound location, but tunneling and undermining may be occurring. Deeper tissue like muscle and bone should not be visible.
Stage four is the most severe of the classic pressure wound conditions. At this level, full-thickness skin and underlying tissue have been lost. Tendon, ligament, bone and muscle tissue may all be exposed and visible. Complications such as rolled edges, tunneling and undermining are common and should be anticipated.
Unstageable pressure wounds
In an unstageable pressure wound, the physician’s judgment is impaired by the condition of the wound site. According to Deep Nursing Quality Insights, the extent of the skin and tissue loss typically cannot be determined. Dead tissue like slough or eschar obscure the wound and must be removed before an accurate diagnosis can be made. Once this happens, doctors should expect to encounter either a stage three or four pressure injury.
Suspected deep tissue injury
Proposed by the NPUAP, suspected deep tissue wounds refer to a type of injury caused by pressure ulcers. Long known as purple pressure ulcers, these growths typically deteriorate and take on the appearance of a deep bruise. These injuries will appear mild until they rapidly reach stage three or four. This classification was developed so that doctors may act quickly before the wound has time to cause full tissue damage.
These pressure wound distinctions are important medical tools that quickly alert the health care personnel involved to the situation at hand. The first step to successful wound care is determining the depth of the injury.
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