Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 9

CLINICAL PRACTICE GUIDELINE

normal) or a blood-filled blister due to damage of
underlying soft tissue from pressure and/or shear.
The area may be preceded by tissue that is
painful, firm, mushy, boggy, warmer, or cooler as
compared to adjacent tissue. sDTI may be difficult
to detect in individuals with dark skin tones.
Evolution may include a thin blister over a dark
wound bed. The wound may further evolve and
become covered by thin eschar. Evolution may be
rapid, exposing additional layers of tissue even
with optimal treatment.

The Use of Staging
in Clinical Practice
Staging of a pressure ulcer using the criteria
outlined previously is widely accepted as a proxy
for severity. However, it should be noted that the
term "staging" is an anatomical description of
a wound, rather than a physiological term, and
that pressure ulcer staging is only appropriate
for defining the maximum anatomic depth of
tissue damage.
It is correct to restage a worsening pressure
ulcer from visit to visit. If a patient with a known
category/stage II pressure ulcer presents at the
next visit with exposure of the adipose layer,
where previously it had only been partial
thickness skin loss, the ulcer should be restaged
as a category/stage III ulcer. Similarly, if a
previously assessed sDTI develops eschar, which
precludes an assessment of the true ulcer depth,
it should be restaged as unstageable.
The progressive numerical identification of
staging can be misleading in that it seems to
imply that a wound must progress sequentially
through each category/stage. This is reinforced
by the observation that a category/stage IV wound
seems to exhibit more tissue damage than a
similarly sized category/stage I wound over the
same area. Although tissue damage may appear
superficial, it may actually begin deep inside the
tissues, close to the bone, and only later manifest

on the skin. Visually, the skin may appear
intact yet discolored, but the muscle, unseen
underneath the skin, may actually be damaged
or even necrotic.
Conversely, with regard to healing, deep
partial and full thickness stages II, III, and IV
pressure ulcers do not heal by restoration of
individual tissue layers (i.e., restoration of the
adipose layer followed by restoration of the
dermis and then the epidermis), but rather by
reparation with inflammation, granulation, matrix
formation, and remodeling (Brown-Etris, 1995;
Cooper, 1995). Therefore, it is never correct to
"reverse" stage pressure ulcers from category/
stage IV to category/stage III to category/stage II
to category/stage I. The tissue defect of a
category/stage IV ulcer that has been replaced by
collagen scar should be referred to as a healing
category/stage IV ulcer if tissue integrity is not
yet restored, and ultimately as a healed category/
stage IV pressure ulcer when the area is fully
epithelialized. It should be noted, however, that a
superficial partial thickness ulcer (category/stage
II) may heal by re-epithelialization with epithelial
migration without scar formation and the skin
may return to its normal state without evidence
of tissue damage (Brown-Etris, 1995).
It is extremely important to correctly stage a
wound upon first presentation as differently
staged wounds have different natural histories
and prognoses for healing. For example, while
sDTI may not appear severe upon initial
observation, one case series noted that
deterioration may be rapid with 26% of sDTIs
becoming full thickness wounds an average of
6 days later, despite the use of pressure
redistribution support surfaces and ulcer
prevention education in nearly all, and 52% of
sDTIs becoming full thickness wounds (category/
stage III and IV) within 1 week in another
different case series (Richbourg, 2011).

Prevalence of Pressure
Ulcers in Persons
with SCI
Historically, more than one-third of
individuals admitted to specialized SCI units
develop pressure ulcers during acute care or
rehabilitation (Yarkony and Heinemann, 1995;
Mawson et al. 1988; Young and Burns (1981a,
1981b)) and the prevalence rates of pressure
ulcers for persons with SCI residing in the
community have ranges from 17%-33% (Carlson
et al., 1992; Fuhrer, et al., 1993).

9
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

Table of Contents for the Digital Edition of Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury
