Byram Healthcare

Pressure Injuries

3 Condition contribute to skin breakdown:

•Friction

•Shear

•Moisture

Classification schemes vary depending on the type of wound. First we will discuss--

Pressure Injuries Three conditions contribute to skin breakdown in pressure injuries, including friction, shear, and moisture. Friction is abrasion that removes the outermost layer of skin (stratum) and damages underlying skin layers, which are more delicate and subject to damage than the skin. Shear combines gravity and friction, causing the separation of tissue parallel to skin surface. The impact of shear depends on pressure, “slipperyness” between materials, and how much skin is in contact with surfaces. This type of wound appears shaved without cratering and is usually present over a large surface area. Moisture may be present from incontinence or perspiration and may cause maceration and overhydration of the epidermis. This makes the skin less tolerant to pressure forces.

Stage	Definitions
I	Non-blanchable erythema of intact skin.
II	Partial thickness skin loss involving epidermis and/or dermis.
III	Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. This presents clinically as a deep crater.

According to the WOCN guidelines, a pressure injury is any lesion caused by unrelieved pressure resulting in damage to the underlying tissue. Pressure injuries usually occur over boney prominences and are staged to classify the degree of tissue damage. During the National Pressure Ulcer Advisory Panel’s 2016 Staging Consensus Conference in April 2016 an updated set of staging definitions was validated. We will describe the updated terminology and definitions here.(1)

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. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 2: Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible 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. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

Stage 3: Pressure Injury: Full-thickness skin and tissue loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) 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. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Stage	Definitions
IV	Full thickness loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures.
Unstageable	Covered with eschar or slough.
Suspected deep tissue injury	Purple or maroon in color. Localized area of discolored intact skin or blood-filled blister due to damage or underlying tissue.

Stage 4: Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Unstageable: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. (Suspected) Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.