Name that ulcer stage

As increasing numbers of patients leave hospitals soon after major surgeries, wound care is becoming a bigger part of the home care nurse’s duties.

So like it or not, your staff will need to know some basic wound care assessment skills, including the staging of wounds, as approved by the National Pressure Ulcer Advisory Panel.

Most wounds occur over bony prominences, and along with identifying the wound’s stage, nurses should identify exactly where the pressure ulcer has occurred by naming the bony prominence, says Lori Mitchell, RN, BSN, patient/staff education coordinator of St. John’s Visiting Nurse Association in Springfield, MO.

These universal classes of ulcers describe the severity of pressure ulcers. The stages are as follows:

Stage I: Nonblanchable erythema of intact skin, which means the wound’s redness does not turn white. "If you have nonblanchable erythema of skin on top, it could signify deeper tissue damage," Mitchell explains. "The most pressure is where tissue lies next to the bone."

Stage II: The ulcer affects the epidermis and/or dermis, usually as an abrasion, a blister, or shallow crater. This is any breakdown of the skin that is superficial.

Stage III: Full thickness skin loss, involving necrosis of subcutaneous tissue, which is the tissue beneath the first two layers. "It can be dark; it can be sloughy looking with a yellow area in it, and that tissue may extend down to, but not through, underlying fascia, which is the tendons, bones, supporting structure," Mitchell says.

Stage IV: Extensive damage to the muscle, bone, or supporting structures. Nurses won’t always be able to tell whether it’s a stage IV ulcer by looking at the wound because the eschar, which is a scab, may cover it. "We won’t know how deep it is until the eschar comes off," Mitchell says. "A lot of times what looks like a stage I or II ulcer becomes much deeper once we start working on it."

Mitchell suggests that nurses assess the depth, width, and length of the ulcer.

"We also assess for any tunneling or undermining of the wound," she says.

The wound might appear to be round, but it goes farther back underneath the tissue. "You have to assess that by using a swab or something to go underneath or around the edges of the wound to see if there’s any open space back there."