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The 2016 NPUAP Pressure Injury Staging System
Joyce Black, PhD, RN, CWCN,
FAAN
March 21, 2017
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
The 2016 NPUAP Pressure Injury Staging System
Joyce Black, PhD, RN, CWCN, FAAN
3
Continuing Education Disclosures
Commercial Support or Sponsorship – None
Speaker or planner conflicts of interest – None
For Nursing credit or attendance certificate:
Full session attendance and completion of one on-line evaluation.
No products or services are endorsed by MetaStar or any accrediting agency.
Evaluation link –
https://www.surveygizmo.com/s3/3398124/March-21-2017-LSQIN-Pressure-
Injury-Definition-and-Stages-Changes-to-the-Staging-System-in-2016
The participant is responsible for determining if the educational activity is
acceptable to meet CE requirements to renew licensure in their state
Thank you!
4
Learning Objectives
• Following this webinar, participants will be
better able to:
– Describe the rationale for changing the term pressure
ulcer to pressure injury.
– Identify the changes in the 2016 NPUAP staging
system.
– Identify pressure injury prevention and treatment
strategies
Process
• Task force appointed in 2014 to review current
staging terms
• Laura Edsberg, Laurie McNichol, Margaret
Goldberg, Lynn Moore, Mary Siegreen and Joyce
Black
• Over 3000 papers reviewed
• Draft definitions sent out for review and comment
• Consensus meeting held April 2016
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 5
Since April 2016
• Staging system endorsed by
– Wound, Ostomy and Continence nurses Society (WOCN)
– Centers for Medicare and Medicaid Services (CMS) for
upcoming work
– The Joint Commission
– World Health Organization for ICD-11
– Many health care organizations
– Many health care associations
• Except Association for the Advancement of Wound
Care (AAWC)
– Pointed negative statements about the use of the word
“injury”, the consensus process and even the task force
members
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 6
Why the word “injury”?
• Stage 1 and Deep Tissue Injury were never
ulcers
• An ulcer cannot be present without an injury, but
an injury can be present without an ulcer
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 7
Is there greater legal exposure?
• Legal cases on pressure injury/ulcer begin because:
– The patient or family has an expected outcome which
leads to frustration or anger
– The standard of care was not met
– The pressure injury was avoidable
– Cases are not brought forth because of their name
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 8
Does the word “injury” makes these cases more litigable? • We asked multiple malpractice attorneys
• We had no early concerns for the change by
stakeholders
• We have had no concerns expressed by those who
have endorsed the new terms
• No one knows
– The change from decubitus to pressure ulcer did not change
the case law
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 9
Publication
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 10
The Updated Staging System
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 11
Anatomy of the Skin
• Largest organ of the body
• When intact, serves as the
primary prevention from
invasion
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
12 9
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Layers of the skin
• Epidermis - dry keratinocytes
• Rete pegs bind the two layers
• Dermis - living layer contains
nerves, vessels, lymphatics, hair
follicles
• Two layers
– Papillary (superficial)
– Reticular (deeper)
» Contains epidermal
elements that support
healing
13
Anatomy of the Skin
10
Pressure Injury Definition
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 14
• A pressure injury is localized damage to the skin and
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.
• A pressure injury is localized damage to the skin and 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.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 15
Pressure Injury Definition - changes
Stage 1 Pressure Injury: 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.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 16 13
• Pale or whitish areas on the skin as blood flow to
the region is prevented by a finger or plastic disc
(diascopy).
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 17
Blanch Response
14
• To determine blanching
− Apply light pressure for a few seconds
− Release and watch for quick return to usual skin color
• Blanchable
– Skin color returns immediately
• Non-blanchable erythema
– The lack of a blanche response
occurs when light pressure is
applied or, persistent redness in
lightly pigmented skin
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 18
Blanch Response
15
• Stage 1 Pressure Injury was discovered on tissue
that had been exposed to pressure in combination
with shear
• Patient was laying supine
when the injury pressure
injury occurred
• Pressure injury is located
on the buttocks rather than
the sacrum
• The linear mark is from a fold in the linen
19 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Stage 1 Pressure Injury Example
16
• Melanocytes in the epidermis
– Produce melanin pigment to absorb radiant energy
and protect the skin from harmful ultraviolet (UV)
radiation
• Causes of skin tone variations
– Sun exposure
– Gender
– Race
– Hormones
– Age
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 20
Pigmented Skin
17
• Intact skin with a localized area of non-blanchable
erythema, which may appear differently in darkly
pigmented skin.
− Pigmentation of the skin may
prevent visualizing the reactive
hyperemia in the pressure injury
− Moistening the skin will often aid
in visualizing color change
− Ask about pain in the area
− Palpate the skin for induration
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 21
Stage 1 in Darkly Pigmented Skin
18
• Darkly pigmented skin does not
have a visible blanche response
• Examine the skin for other
changes indicating pressure
injury
– Discoloration compared to
surrounding skin
– Pain in the area
– Induration
22
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Stage 1 Pressure Injury Example
19
• 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.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 23
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis
20
• 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).
IAD ITD Skin Tear
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 24
Stage 2 Pressure Injury Definition
21
• Appearance
– Shiny, red
– Visible blood vessels in
reticular layer
– Edge may be distinct in
thick tissue or beveled in
thin tissue
• Painful
• May have serious drainage
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 25
Characteristics of Viable Dermis
22
• Exposure of reticular
layer of dermis
– Capillary buds visible
– Can look like slough
– Is not removable
26
Paraplegic with thickened
skin due to slide transfers
creates a visible edge to
the ischial stage 2 injury
Appearance of Stage 2
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 23
Lateral Heel Thigh and Scrotum
from Medical
Device
Anterior Chest
from Prone
Position while in
Operating Room
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 27
Stage 2 Pressure Injury Examples
24
Epithelialization
• Presence of epithelial
cells in dermis promotes
healing without a scar
and contracture
• Pigmentation seldom
returns
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 28
Stage 2 Pressure Injury Healing
25
• 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 or bone is not
exposed. If slough or eschar obscures
the extent of tissue loss this is an
Unstageable Pressure Injury.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 29
Stage 3 Pressure Injury: Full-thickness skin loss
26
• Epibole (ee-PIB-oh-lee)
• Rolled edge
– Due to lack of tissue in the wound bed to support the
epidermal cells to cross the wound bed
– Needs to be removed
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Area of
Focus
30
Stage 3 Pressure Injury with Epibole
27
Full thickness pressure injury
heals by:
• Granulation tissue
− Capillary buds
• Contracture
− May create epibole
• Epithelialization over
the scar
− Fragile for at least a year
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 31
Stage 3 Pressure Injury Wound Bed
28
Slough (sluf)
Eschar (ES’- car) Dried inflammatory fluids that
are moist, stringy; and yellow,
tan, gray, green or brown
Necrotic tissue that is
leathery or thick; and black,
brown or tan
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 32
Ulcer Surface Appearance
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Ischium Sacrum Heel
33
Stage 3 Pressure Injury Examples
30
Stage 4 Pressure Injury: Full-thickness loss of skin and tissue
• 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.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 34 31
Tendon Bone Muscle
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 35
Stage 4 Pressure Injury Examples
32
Unstageable Pressure Injury: 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 an ischemic limb
or the heel(s) should not be
softened or removed.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 36 33
Unstageable Pressure Injury Examples
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Unstageable Injury
on the Sacrum
Unstageable Injury
on the Lateral Heel
Unstageable on
the nasal bridge
from NIPPV
37 34
Deep Tissue Pressure 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.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 38 35
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.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 39
Deep Tissue Pressure Injury
• Day 1 - Classify intact, discolored skin this pressure as a Deep
Tissue Pressure Injury
• Day 3 - Classify discolored skin with epidermal blistering as a
Deep Tissue Pressure Injury
• Day 10 - If the Deep Tissue Pressure Injury becomes necrotic,
classify it as an Unstageable Pressure Injury
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 40
Day 1 - DTPI Day 3 - DTPI Day 10 - Unstageable
Evolution of Deep Tissue Pressure Injury
• Due to the thickness of the skin, the epidermal
separation will remain intact for a longer
period of time. This phase can be mistaken
for skin tears.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 41
Evolution of DTPI in Darkly Pigmented Skin
38
Deep Tissue Pressure Injury Definition
• Do not use Deep Tissue Pressure Injury (DTPI) to
describe vascular, traumatic, neuropathic, or
dermatologic conditions.
Traumatic
Bruising
Vasopressor
Ischemia Coumadin
Necrosis
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 42 39
Deep Tissue Pressure Injury Examples
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Buttocks Lateral Heel
43 40
Medical Device Related Pressure Injury
• Medical device related
pressure injuries result from
the use of devices designed
and applied for diagnostic or
therapeutic purposes. The
resultant pressure injury
generally conforms to the
pattern or shape of the
device. The injury should be
staged using the staging
system.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 44
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 45
Unstageable Deep Tissue
Pressure Injury Stage 4
Stage 2 Stage 3 Stage 1
Medical Device Related Pressure Injury Examples
Mucosal Membrane Pressure Injury
Mucosal membrane pressure injury is found on mucous
membranes with a history of a medical device in use at
the location of the injury. Due to the anatomy of the
tissue these ulcers cannot be staged.
There is no epidermis or dermis in this tissue
– Upper layer is epithelium
– Columnar cells produce mucus
– Laminar layer provides support
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Add New
Artwork
46 43
Mucous Membrane Ulcers Examples
47 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Tongue Injury from
Endotracheal tube
Lip Injury from
Endotracheal Tube
44
If More Than One Type of Tissue is Exposed
• Stage a pressure injury
according to the deepest
layer of tissue exposed,
i.e. adipose, muscle, bone
• If the extent of tissue
damage cannot be
confirmed because it is
obscured by slough or
eschar, then it is staged
as an Unstageable
Pressure Injury
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 48
Pressure Injury Staging
Before staging a pressure injury
• Determine that the cause of the injury
− Is the injury from pressure or pressure in
combination with shear?
− Is the injury from moisture associated skin
damage (incontinence associated dermatitis,
intertriginous dermatitis), medical adhesive
related skin injury or traumatic wounds (skin
tears, burns, abrasions).
• Cleanse the wound to remove any loose tissue
or other debris
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 49
• History of injury (if known)
– Date of discovery, including Stage
• Location
– Use anatomical terms
– Note medical or other device in use
• Measurements
– Length, width, depth, tunnels, undermining
• Wound characteristics
– Wound bed appearance, amount of drainage, odor,
periwound skin condition, etc.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 50
Pressure Injury Staging: Additional Documentation
A Closer Look at Medical Device Pressure Injury
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 51
Medical Device Related Pressure Injury Examples
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 52
Unstageable Deep Tissue
Pressure Injury Stage 4
Stage 2 Stage 3 Stage 1
• Localized injury to the skin or underlying tissue as a
result of sustained pressure from a device (Black, 2010)
– Tissue injury mimics the shape of the device
– Tend to progress rapidly due to lack of adipose tissue
MDR Pressure Ulcer
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 53
Incidence
Cervical collars
Immobilzers
O2 tubing
Stockings/ boots
NG tubes
22%
17% 13%
12%
8%
Data from Apold, 2012)
Scope of the Problem
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 54
Location Device Non Device
Head/face/neck 70.3% 7.8%
Other/multiple 21.9% 5.8%
Heel/ankle/foot 20.3% 16.9%
Coccyx/buttocks 7.8% 67.5%
Sacrum 1.6% 16.9%
Extent of the Problem
Data from Apold and Rydrych, 2012
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 55
• 74 percent of MDRPrU were not identified until they
were a stage III, IV or unstageable
• 63 percent of cases had no documentation of
– Skin inspection
– Device removal q shift
– Pressure relief
Data from Apold and Rydrych, 2012
Extent of the Problem
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 56
Reducing MDRs- Trach collar/straps
• 66.7 percent of ulcers in skilled care
were due to trach ties (Jaul, 2011)
• Issues
– Airway is #1
– Face plate often sutured in
place
– Trach ties often tied tightly to secure trach
tube
– Ties lost in obese skin folds of neck
– Proxemics to major vessels can create fatal
erosion
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 57 54
Trach Collar Pressure Ulcers
• Prevention
– Work with MDs who place the trachs
• Can sutures come out after 5 days?
– Work with RT
• Frequency of securement device changes
• Change ties with trach care
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 58 55
Trach Collar Pressure Ulcers
• Prevention
– Nursing
• Use thicker, wider foam collar straps to pad skin
• Pad skin around stoma
• Check for ulcers beneath straps on each shift
• Look closely at securements in neck folds
• Find ties and move them daily
• Line entire neck with dressings
Silver dressings reduced ulcers and peristomal skin
injury (Kuo, 2013)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 59 56
CPAP-BiPap Facial Ulcers
• Issues – Develop quickly due to thin
tissue
– Visible injury
– Device applied tightly to
maintain O2 sats
• Prevention – Work with RT to apply dressing prior to O2
– Bundle dressings to devices
– Line nasal bridge and cheeks with foam dressings before placement
– Switch to total face mask before 12 hours (Lemyze, 2013)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 60 57
Oral Mucosal Pressure Ulcers
• Issues
– Airway is priority #1
– Severity underappreciated
• May not be seen as serious
since scar seldom develops
• Prevention
– Rotate device
• RT to help with ET tubes
• Move with each position change
– Check length before
securing
– Use securement devices that can
be loosened
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 61
Oxygen Tubing Ulcers
• Issues – Incidence up to 37 percent
– NC tends to move out of nares
• causes tightening of device
• Prevention – Inspect skin on each shift
– Educate patient to report discomfort
– Pad high risk areas
– Bundle device to O2 tubing
– Use silicone O2 tubing
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 59
Elastic Stockings
• Issues
– Should not be used on
patients with PVD!
– Fitted without measurement
– Fitted while patient is dry,
become tight with edema
• Prevention
– Measure first
– Remove daily-twice daily
to inspect skin
• Especially thighs
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 60
Cervical Collars
• Incidence (Davis, 1995)
– Days 0-4 = 33 percent
– Days over 5 = 55 percent
• Found on occiput, face, chin, chest
• Prevention
– Change to soft collar
– Ensure collar fit
– Assess skin (remove device)
– Pad occiput
• 89 percent reduction in PrU
(Jacobson, 2008)
– Change pads
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 61
NG Tube Ulcers
• Prevention
– Check placement of NG daily
• Can coil in posterior pharynx
– Change to soft feeding tubes when able
– Securement to be free floating in nare
– Move tube when head turned to the side
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 62
Genital MDR PrU
• Issues
– Tubing too short
– FMS designed with ridges
for support
• Prevention
– Use indwelling for urinary
monitoring only
– Intermittent cath preferred
– Check location of tubing with each reposition
• Leave slack in tubing
– Tape Foley to lower abdomen in males
• Prevents penile shaft tears
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 63
• Do we tell the product manufacturer of the
issue with MDR PrU?
• If so, what is the response?
– My experiences have been both positive and
negative
• Extension on neck collar
• Silicone oxygen tubing
• Revisions in Foley cath
• Reengineering of CPAP mask
The Role of Manufacturing
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 67
• NPUAP serves as the authoritative voice for
improved patient outcomes in pressure injury
prevention and treatment through public policy,
education and research.
NPUAP’s Role
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 68
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org 69
Questions
This material was prepared by the Lake Superior Quality
Innovation Network, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the
U.S. Department of Health and Human Services. The
materials do not necessarily reflect CMS policy.
11SOW-MI/MN/WI-C2-17-248 032017
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