How to Stage Decubiti for Documentation in your Nurse's Notes
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Describing a patient's wound is critical to good and consistent care. The staging system described on this page helps to provide good documentation but is specific only to decubiti (pressure ulcers). It is not used for diabetic ulcers, trauma, or stasis ulcers.
Traditionally, the wounds discussed on this page were call decubitus (singular) or decubiti (plural). The word "ulcer" added to that (i.e., decubitus ulcer) is actually unnecessarily repetitous as decubitus is always an ulcer. More recently pressure ulcer has been used frequently.
Staging on an Artificial Tissue Model
Not only static pressure, but friction and shearing can cause tissue damage and pressure ulcers.
In order to determine if a red area on the body is a stage 1 pressure ulcer, it needs to be tested to see if it blanches or not. If it does not blanche (remains red in spite of applying pressure to the area) then it is a stage 1.
You can see clearly that the area blanches and therefore is not a stage 1.
Stages of Decubiti
Stage 1: Red, unblanchable, intact skin. So if you notice any drainage, it is no longer intact skin
Stage 2: Shallow open pressure ulcer where the epidermis is gone but the dermis is still intact. Think road rash in terms of look and depth.
Stage 3: Ulcer that is crater like, goes thru the epidermis and dermis. There may be necrosis or slough in the wound and depending on the weight of the patient, difficult to tell the difference between adipose tissue and slough, though my own experience seems to be the adipose tissue is very yellow whereas the slough is cream, light yellow, tan, grey, green or brown.
Stage 4: Pressure ulcer that exposes muscle, tendon or bone. It may have dead tissue attached to the exposed area but it does not obscure the actual depth of the wound.
Unstageable: Covered with eschar or slough to the point where you don't know how that dead tissue goes until you hit viable tissue. I often tell patients that as this type of decubiti heal, it appears to be getting worse because the depth increases as the dead tissue is removed.
Suspected Deep Tissue Injury: As in stage one, this type of decubiti has the epidermis intact, no drainage but is usually more purple in color. It also may be a blood filled blister that feels very indurated or boggy. That kind of feel to the underlying tissue leads one to believe there is more damage than can be seen.
The physical depth does not determine the stage, it is what structures are exposed or easily palpated. So a pressure ulcer on the bridge of the nose could be very shallow yet be considered a Stage 4 because the bone is exposed.
Pressure ulcers can progress from stage 1 to 2 to 3 to 4, but you cannot reverse stage a healing ulcer. Which can be difficult to keep an accurate history.
Imagine documenting a stage 4 on the coccyx, have it heal and close, so it would be considered a healed stage 4. Now imagine the patient going home and then getting readmitted to the hospital in a few months. Technically, the admitting nurse should document the the coccyx as a healed stage 4.
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