Long-Term Care

Staging pressure ulcers

LTC Nursing Assistant Trainer, December 31, 2009

Pressure ulcer staging is an assessment system that classifies pressure ulcers based on anatomic depth of soft-tissue damage. The staging system only describes the condition of the ulcer at the time of the initial assessment.

For years, nurses staged healing wounds in reverse order. Thus, a wound would theoretically heal from a Stage IV to III, II, and I. Reverse staging is not recommended, because healing ulcers do not replace lost muscle, subcutaneous fat, or dermis before they reepithelialize. Instead, the ulcer is filled with granulation (scar) tissue composed primarily of endothelial cells, fibroblasts, collagen, and extracellular matrix. Reverse staging does not accurately reflect physiologic changes to an ulcer. Once a Stage IV ulcer exists, it is always a Stage IV. If the ulcer improves, document it is a “healing Stage IV.” Validate your opinion by documenting characteristics of the wound, such as width, depth, presence or absence of necrotic tissue, exudate, and presence of granulation tissue. Be descriptive. Avoid statements such as “healing slowly” or “healing well.”

This is an excerpt from HCPro’s book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

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