Accurate assessment of stage II pressure ulcers.

OSTOMY WOUND MANAGEMENT APRIL 2009 www.o-wm.com Two recent events relate to pressure ulcers. In February 2007, the National Pressure Ulcer Advisory Panel (NPUAP) restated its definitions of and staging process for pressure ulcers. Included in the staging process are modifications of the original four stages plus new categories: deep tissue injury and unstageable. In October 2008, the Centers for Medicare and Medicaid Services (CMS) put into effect “non-payable codes” for Stage III and Stage IV pressure ulcers that develop in a hospital setting. These changes underscore the need to understand Stage II pressure ulcer staging and assessment. According to the NPUAP’s former definitions, Stage II pressure ulcers were described as partial-thickness skin loss involving the epidermis or dermis; the ulcer presents clinically as an abrasion, a blister, or a shallow crater. In the new definition, Stage II is described as partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough; the ulcer may also present as an intact or open/ruptured serum-filled blister. Thus, if slough is noted at the base of the wound, it is not a Stage II ulcer. After identifying the stage of the ulcer, the next step is to determine factors contributing to skin breakdown. Key elements to address are nutrition, incontinence, immobility, and location. Consider what is happening at the ulcer location to cause the breakdown. Are circumstances controllable? Ask the patient leading questions in a non-judgmental, inquisitive manner to glean important insights — eg, the patient admits to sleeping in the same position all day, leading to skin breakdown. Stage II pressure ulcers are “ulcers of opportunity” because contributing causes can be identified and interventions implemented before further damage occurs. ■ PEARLS FOR PRACTICE