The 2016 NPUAP

Pressure Injury Staging

System
Joyce Black, PhD, RN, CWCN,
FAAN

March 21, 2017

The 2016 NPUAP Pressure
Injury Staging System

Joyce Black, PhD, RN, CWCN, FAAN

©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

 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!

3
 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

4
 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

5 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

 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
6 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
 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

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 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

8 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

 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

9 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

 Publication

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 The Updated
Staging System

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 Anatomy of the Skin

• Largest organ of the body

• When intact, serves as the

primary prevention from
invasion

9 12
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
 Anatomy of the Skin

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

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 Pressure Injury Definition

• 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.

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 Pressure Injury Definition - changes

• 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.

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 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.

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 Blanch Response

• Pale or whitish areas on the skin as blood flow to

the region is prevented by a finger or plastic disc
(diascopy).

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 Blanch Response

• 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

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 Stage 1 Pressure Injury Example

• 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

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 Pigmented Skin

• 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

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 Stage 1 in Darkly Pigmented Skin

• 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

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 Stage 1 Pressure Injury Example

• 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

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22
 Stage 2 Pressure Injury:
Partial-thickness skin loss with exposed dermis

• 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.

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 Stage 2 Pressure Injury Definition

• 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

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 Characteristics of Viable Dermis

• 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

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 Appearance of Stage 2

• Exposure of reticular
layer of dermis
– Capillary buds visible
– Can look like slough
– Is not removable

Paraplegic with thickened

skin due to slide transfers
creates a visible edge to
the ischial stage 2 injury

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 Stage 2 Pressure Injury Examples

Lateral Heel Thigh and Scrotum Anterior Chest

from Medical from Prone
Device Position while in
Operating Room

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 Stage 2 Pressure Injury Healing

Epithelialization
• Presence of epithelial
cells in dermis promotes
healing without a scar
and contracture
• Pigmentation seldom
returns

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 Stage 3 Pressure Injury:
Full-thickness skin 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 or bone is not
exposed. If slough or eschar obscures
the extent of tissue loss this is an
Unstageable Pressure Injury.

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 Stage 3 Pressure Injury with Epibole

• 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

Area of
Focus

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 Stage 3 Pressure Injury Wound Bed

Full thickness pressure injury

heals by:
• Granulation tissue
− Capillary buds
• Contracture
− May create epibole
• Epithelialization over
the scar
− Fragile for at least a year

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 Ulcer Surface Appearance

Slough (sluf) Eschar (ES’- car)

Dried inflammatory fluids that Necrotic tissue that is
are moist, stringy; and yellow, leathery or thick; and black,
tan, gray, green or brown brown or tan

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 Stage 3 Pressure Injury Examples

Ischium Sacrum Heel

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 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.
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 Stage 4 Pressure Injury Examples

Muscle Bone Tendon

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 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.
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 Unstageable Pressure Injury Examples

Unstageable Injury Unstageable on Unstageable Injury

on the Sacrum the nasal bridge on the Lateral Heel
from NIPPV

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 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.
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 Deep Tissue Pressure Injury

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.

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 Evolution of Deep Tissue Pressure Injury

Day 1 - DTPI Day 3 - DTPI Day 10 - Unstageable

• 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
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 Evolution of DTPI in Darkly
Pigmented Skin

• 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.
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 Deep Tissue Pressure Injury Definition

• Do not use Deep Tissue Pressure Injury (DTPI) to

describe vascular, traumatic, neuropathic, or
dermatologic conditions.

Vasopressor
Traumatic Ischemia Coumadin
Bruising Necrosis

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 Deep Tissue Pressure Injury Examples

Buttocks
Lateral Heel

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 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.

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 Medical Device Related Pressure Injury
Examples

Stage 1 Stage 2 Stage 3

Stage 4 Unstageable Deep Tissue

Pressure Injury
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 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 Add New
Artwork

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 Mucous Membrane Ulcers Examples

Tongue Injury from Lip Injury from

Endotracheal tube Endotracheal Tube

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 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

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 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

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 Pressure Injury Staging:
Additional Documentation

• 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.

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 A Closer Look at
Medical Device
Pressure Injury

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 Medical Device Related
Pressure Injury Examples

Stage 1 Stage 2 Stage 3

Stage 4 Unstageable Deep Tissue

Pressure Injury
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 MDR Pressure Ulcer

• 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

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 Scope of the Problem

Incidence

8% Cervical collars

Immobilzers
12% 22%
O2 tubing

Stockings/ boots
13% 17% NG tubes

Data from Apold, 2012)

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 Extent of the Problem

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%

Data from Apold and Rydrych, 2012

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 Extent of the Problem

• 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

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 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

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 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

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 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)

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 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)

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 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
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 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

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 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

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 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

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 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

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 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
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 The Role of Manufacturing

• 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

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 NPUAP’s Role

• NPUAP serves as the authoritative voice for

improved patient outcomes in pressure injury
prevention and treatment through public policy,
education and research.

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 Questions

69 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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