Nursing Home Pressure Sore Staging
Pressure sore staging – according to the Mayo Clinic, pressure sores or pressure ulcers also called “bedsores” — are injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks. The elderly and people with medical conditions are at greater risk of bedsores especially if they require assistance with repositioning or turning themselves in bed or their wheelchair. The sores can develop quickly and once they occur can be difficult to heal, therefore prevention of pressure ulcers is very important.
Pressure Sore Staging
Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.
A Stage I pressure ulcer is an observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following:
skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching).
The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers.
NPUAP Free Resource Category/Staging Illustrations:
- Category/Stage One
- Category/Stage Two
- Category/Stage Three
- Category/Stage Four
- Suspected Deep Tissue Injury
Pressure Sore Staging – PUSH Tool
The Pressure Ulcer Scale for Healing (PUSH Tool) was developed by the National Pressure Ulcer Advisory Panel (NPUAP) as a quick, reliable tool to monitor the change in pressure ulcer status over time.
- PUSH Tool (web version)
- PUSH Tool (pdf version)
- Reprint Agreement (pdf)
- Information and Registration Form
- Instructions for Using PUSH
Pressure Sore Staging – Prevention
In addition to repositioning and turning bedsores, pressure sores can also occur from either a single source or a variety forms of neglect working together, such as dehydration, medical overdose, medical devices such as splints or braces, feet dragging from a wheelchair and many other preventable sources. Care and attention should be given to ensure that every resident is receiving care in compliance with their plan of care, including adequate hydration, nutrition, hygiene, and assistance with repositioning to avoid pressure sores. Federal regulations state that the facility must ensure that—a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 42 CFR 483.25(c)
If you have questions about pressures sores or other neglect or abuse to a nursing home resident contact attorney Kenneth LaBore at 612-743-9048 or toll free at 1-888-452-6589 or by email at: klabore@MNnursinghomeneglect.com