The National Pressure Ulcer Advisory Panel (NPUAP), a not-for-profit organization of pressure injury experts, recently made changes to the terminology and staging system used for the identification and assessment of pressure ulcers. There are significant implications for care providers, so having an understanding of the new terminology is advised. Notable changes to the industry-standard nomenclature and related definitions include:

• The replacement of the term “pressure ulcer” with “pressure injury,” which the panel felt was more inclusive and descriptive of wounds to both intact and ulcerated skin. The reasoning is that the previous usage of “ulcer” may have been confusing when dealing with damage to intact skin
• An updated definition of “pressure injury,” now described as “localized damage to the skin and/or 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 soft tissue.”
• The usage of Arabic numbers, rather than Roman numerals, in staging nomenclature. So, instead of documenting a “Stage II Pressure Ulcer,” the provider will now document the presence of a “Stage 2 Pressure Injury.”
• The removal of the term “suspected” from the “Deep Tissue Pressure Injury” diagnostic label.
• The addition of two new definitions to the nomenclature: “Medical Device Related Pressure Injury,” and “Mucosal Membrane Pressure Injury.”

The NPUAP’s updated and new staging definitions include:

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin is visible with a localized area of non-blanchable erythema and changes in sensation, temperature, or firmness may precede visual changes.

Stage 2 Pressure Injury: 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.

Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness skin loss in which adipose fat is visible in the ulcer and granulation tissue and epiboly are often present along with the possibility of slough and/or eschar which might be visible. The depth of tissue damage varies by anatomical location and areas of significant adiposity can develop deep wounds.

Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the injury is classified as Stage 4. Visible slough and/or eschar might be present and epiboly (rolled edges), undermining, or tunneling often occur and depth can vary depending on the location of the injury.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Slough or eschar obscures the extent of the tissue damage within the injury. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.

Deep Tissue Pressure Injury: Persistent, non-blanchable deep red, maroon or purple discoloration. The skin can be intact or non-intact skin with a localized area of persistent, non-blanchable dark maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Skin color changes are often preceded with pain and temperature changes. Intense and prolonged pressure and shear forces at the bone-muscle interface cause this injury. The wound may rapidly advance to show the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3, or Stage 4).

Medical Device Related Pressure Injury: Describes an etiology. These injuries result when devices are used for diagnostic or therapeutic purposes. The injury often conforms to the pattern or shape of the device and should be staged using the staging system.

Mucosal Membrane Pressure Injury: Mucosal membrane pressure injury found on mucous membranes with a history of use of a medical device in the location of the injury. These injuries cannot be staged.

These changes to the definition of pressure ulcers/injuries are meant to increase clarity by addressing the fact that not all injuries of this type involve skin breakage or blanching.

Want to learn more about this switch from pressure ulcers to pressure injuries? Check out the official NPUAP press release.