Wound Care: Effectively Staging Pressure Ulcers

In this portion of our wound care article, we’ll be discussing skin integrity issues, particularly, staging pressure ulcers.

Let’s get into it.

How Pressure Ulcers Happen

Also known as decubitus ulcers, pressure ulcers are injuries to the skin and its underlying tissues. The main cause of skin breakdown, especially with skin ulcers, is increased pressure on the site, which leads to ischemia or low oxygen supply.

To give you a better idea, other examples of low oxygen issues happening inside the body are:

• Myocardial infarction (the heart is not getting enough oxygen)
• Deep vein thrombosis (a blockage causes insufficient blood flow)
• Peripheral vascular disease (narrowing of blood vessels, disrupting oxygen perfusion)

Stages of Pressure Ulcers

What are the different stages of pressure ulcer and how does one identify each stage?

Stage 1: Non-blanchable ulcer

What is non-blanching? When you push the skin, the normal reaction would be, that the area turns white, then, it comes back to its original skin color. This is similar to a capillary refill wherein you check clients for peripheral oxygenation. Blanchable is when there is a red ulcer that you’ve pushed and the redness goes away then comes back.

On the other hand, non-blanchable is when you push the skin of your client, and the area stays red that means that there is little or no blood flow going to that area.

Pressure ulcers are mostly seen on bony prominences like the hip, tailbone, and the heels.

Stage 2: Partial thickness

Partial thickness skin loss means that there is a skin break. Now that the skin is open, there is a risk for infection.

Stage 3: The subcutaneous layer

In basic anatomy, the integumentary system is primarily composed of the epidermis, dermis, subcutaneous tissue, and all the way to the muscles and bones. At this stage, the subcutaneous tissues are now visible. This is most prominent around the sacral area or the tailbone.

In the Medical-Surgical ward, nurses take pictures of newly admitted clients especially those who are already experiencing skin breakdown even before they get admitted to prove that they weren’t the ones responsible for the client having the pressure ulcer.

Stage 4: Full-thickness tissue loss

In this stage, the ulcer has gone deeper, reaching the muscles and bones. The muscles and bones are now visible; thus, this condition is termed as tissue necrosis. As this happens, muscles and bones are affected together with the neighboring structures. Stage four pressure ulcers appear as deep pockets, and the client is at increased risk of acquiring a wound-related infection.

Stage 5: Eschar

Considered unstageable, this type of pressure ulcer is charcoal-like and is highly necrotic; thus, the name, eschar. Eschars are sloughed off, necrotic skin that are primarily darkened and dried-up.

In our next topic about pressure ulcers, we’ll be elaborating the risk factors like obesity, smoking, and the reasons for the breaking down of skin. We will also focus on the different nursing considerations to manage and treat the wound, and prevent further damage.

For more useful nursing-related lectures and videos, check out our Simple Nursing website and YouTube channel.