Pressure Ulcers/Injuries:

Assessment and Treatment

Caryn Goolsby BSN, CWOCN
CHI Franciscan Wound Ostomy (Enterostomal Therapy) Department
Objectives

 To update/review on NPUAP (National Pressure Ulcer

Advisory Panel) pressure injury staging system
 To update on NPUAP Support Surface Standards Initiative
(S3I) information, as well as update on the new WOCN
Society’s support surface algorithm
 To inform regarding simple wound care treatments that
can be initiated or delegated post acute care
Overview

 Brief overview of Pressure ulcers/injury staging

 Prevention and Treatment
 Support Surfaces
 General information on moist wound healing
NPUAP staging system
updated in 2016
 Changed wording from ulcer to injury
 Made the wording integrate more with international staging system
 Clarified device related pressure injury and mucus membrane related
pressure injury
 Took away the roman numerals; now standard numbers
 Some controversy over the changes
 Medicare and state DOH have not changed from the “ulcer”
terminology yet
 possibly related to the controversy?
 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.
Stage 1/non-blanchable erythema
of intact skin
 Intact skin with a localized
area of non-blanchable
erythema, which may appear
differently in darkly
pigmented skin.

 Presence of blanchable
erythema or changes in
sensation, temperature, or
firmness may precede visual
changes.
Non-blanchable Erythema

 Usually with clearly

defined margins, can be
indurated, may or may
not be warmer/cooler
than surrounding skin.
Pressure Damage w/Dark
Skin
 Grey/purple hue to skin
 Induration present
 May be mushy or boggy
instead
 Often cannot visualize
damage until top layers of
skin sloughed
Stage 2: Partial thickness

 Partial-thickness loss of skin

with exposed dermis. The
wound bed is viable, pink or
red, moist, and may also
present as an intact or
open/ruptured serum filled
blister.
 Adipose and deeper tissues
are not visible. Granulation
tissue, slough and eschar are
not present.
 These injuries commonly
result from adverse
microclimate and shear in the
skin over the pelvis and
shear in the heel
Stage 2 Pressure injury
Stage 3: Full thickness tissue loss

 Full-thickness loss of skin, in

which adipose is visible in the
ulcer and granulation tissue and
epibole are often present. Slough
and/or eschar may be visible.
 The depth of tissue damage varies
by anatomical location; areas of
significant adiposity can develop
deep wounds. Undermining and
tunneling may occur.
Stage 3
Stage 4: full thickness skin and
tissue loss
 Full thickness skin and tissue
loss with exposed or directly
palpable fascia, muscle, tendon,
ligament, cartilage or bone.
Slough and/or eschar may be
present. Epibole, undermining
and/or tunneling often occur.
 The depth varies by anatomical
location.
 If slough or eschar obscures
the extent of tissue this is an
Unstageable Pressure Injury.
Stage 4