Describe an Unstageable Wound

Proper care for wounds is essential to healing. Types of wounds range from skin abrasions to ulcer wounds. Some wounds, such as pressure ulcers, present particular difficulties for the wound care provider. A staging system has been developed for the assessment of pressure ulcers, but for certain wounds the assessment cannot be performed. Accurate recognition and documentation of when a pressure ulcer is or is not "unstageable" is an important issue for wound care providers.

Background

• Pressure ulcers, sometimes called bed sores, occur when pressure is applied to the same area of the body consistently over a long period, as when lying in bed for a long time without changing position. They are a particular problem for the bedridden and people who use wheelchairs. Wound staging refers to assessment of the wound depth of pressure ulcers.

System

• National Pressure Ulcer Advisory Panel issues guidelines for pressure ulcer care. According to NPUAP guidelines, pressure ulcers are classified as stage I, stage II, stage III or stage IV, depending on the wound characteristics. Besides the four stages and "unstageable," the term "suspected deep tissue injury" is a further classification within the system.

Problems

• According to the Wound Ostomy and Continence Nurses Society, wound staging cannot be performed "until the deepest viable tissue layer or identifiable structure base is exposed, because the deepest viable tissue layer is unknown." The problem occurs when the wound is partially or completely covered with types of dead tissue or scabs, called slough or eschar.

Description

• As of 2010, the NPUAP definition of an unstageable wound is "full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) in the wound bed." The NPUAP adds, "Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed." The new definition was provided in 2007 in response to previous confusions.

Significance

• According to Mary Arnold Long in a 2007 article in Student Nurse Journey, the significance of the new definitions include the description of the slough and eschar, the emphasis on clear visualization of the wound base prior to staging and the specification that dry, intact, stable eschar on the heels should not be debrided as part of the care. Arnold notes the risk for osteomyelitis and even amputation if necrotic heels are debrided. Instead pressure should be removed from the heels and the eschar kept intact and dry, which can be accomplished by using povidone-iodine to paint the heels.