One of the fundamental documentation details when describing a wound is the use of the appropriate classification system. Each classification system is unique to a wound's type, should align with your description of the wound, and be integrated into your documentation details. Let us take a look at one classification system for a common wound type, namely, pressure injuries (PIs).

Over the decades, PIs have had alternate naming conventions such as decubitus ulcers, pressure sores, and pressure ulcers. In 2016, the National Pressure Injury Advisory Panel (NPIAP), formerly the National Pressure Ulcer Advisory Panel, updated the definition of PI and the staging system to classify each PI type.1 The updated definition of PI reads "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."2

PI stages include2:

Stage 1 PI. This occurs as intact skin with a localized area of nonblanchable 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 PI.

Stage 2 PI. This appears as partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) tissue 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. This stage should not be used to describe moisture-associated skin damage, including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (skin tears, burns, abrasions).

Stage 3 PI. This manifests as full-thickness loss of skin, in which adipose (fat) tissue 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, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an unstageable PI.

Stage 4 PI. Full-thickness skin and tissue loss occurs 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 PI.

Unstageable PI. Full-thickness skin and tissue loss occurs 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 PI will be revealed. Stable eschar (ie, dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

Deep Tissue PI. Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration, or epidermal separation reveals 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. 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 PI (unstageable, stage 3 or stage 4). Do not use deep tissue PI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Additional PI Definitions:

Medical device-related PI. This describes an etiology. Medical device-related PIs result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant PI generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

Mucosal membrane PI. Mucosal membrane PI is found on mucous membranes with a history of a medical device in use at the location of the injury. Because of the anatomy of the tissue, these ulcers cannot be staged.

In November 2019, the NPIAP released the third edition of the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, The International Guideline.3 The NPIAP collaborated with the European Pressure Ulcer Advisory Panel and the Pan Pacific Pressure Injury Alliance on the guidelines with contributions from other notable organizations, experts, stakeholders, and patient consumers and their caregivers. The goal of this international collaboration culminated in evidence-based recommendations for the prevention and treatment of PIs for health professionals globally. The full Clinical Practice Guideline is available for purchase in a hard copy or e-version.3 The Quick Reference Guide is available for download and designed for busy health professionals. According to the NPIAP, the Quick Reference Guide is not intended for use in isolation from the Clinical Practice Guideline but provides a quick summary of the evidence-based recommendations, good practice statements, and quality indicators.4

Lastly, the guidelines also provide good practice statements for classification of PIs, including4

differentiate PIs from other types of wounds,

use a PI classification system to classify and document the level of tissue loss, and

verify that there is clinical agreement in PI classification among the health professionals responsible for classifying PIs.

PIs remain one of the biggest challenges facing wound care practitioners today. They affect patients in all healthcare settings. On admission to any facility and routinely thereafter, clinicians should initiate proper protocols or procedures, provide proper intervention pathways to prevent and treat existing PIs, and integrate best practice guidelines within documentation workflows. Effective interventions demand a multidisciplinary team approach that coordinates the needs of the patient. Document diligently!

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