|
PRESSURE
ULCER CLASSIFICATION
DIFFERENTIATION BETWEEN PRESSURE ULCERS AND MOISTURE LESIONS
Defloor T., Schoonhoven L., Fletcher J., Furtado K., Heyman
H.,
Lubbers M., Lyder C. and Witherow A.
SUPPORTED BY THE EPUAP TRUSTEES:
BALE S., BELLINGERI A., CHERRY G., CLARK M., COLIN D., DASSEN T.,
DEALEY C.,
GULACSI L., HAALBOOM J., HALFENS R., HIETANEN H., LINDHOLM C., MOORE
Z.,
ROMANELLI M., VERDU J.
Pressure Ulcer
is an area of localised damage to the skin and underlying tissue
caused by pressure or shear and or a combination of these. The identification
of pressure damage is an essential and integral part of clinical
practice and pressure ulcer research. Pressure ulcer classification
is a method of determining the severity of a pressure ulcer that
is also used to distinguish pressure ulcers from other skin lesions.
A classification system describes a series of numbered grades or
stages each determining a different degree of tissue damage.
The European Pressure Ulcer Advisory Panel (EPUAP) defined four
different pressure ulcer grades (see Table 1). Non blanchable erythema
should be considered as an alarm signal that pressure and shear
are causing tissue damage and preventive measures should be taken
without delay to prevent the development of pressure ulcer lesions
(grade 2, 3 or 4).
Table 1: EPUAP Classification (1)
| Grade |
Short
Description |
Definition |
| Grade 1 |
Non-blanchable
erythema of intact skin |
Non-blanchable
erythema of intact skin.
Discolouration of the skin, warmth, oedema, induration or hardness
may also be used as indicators, particularly on individuals
with darker skin. |
| Grade 2 |
Blister |
Partial
thickness skin loss involving epidermis, dermis, or both. The
ulcer is superficial and presents clinically as an abrasion
or blister. |
| Grade 3 |
Superficial
ulcer |
Full thickness
skin loss involving damage to or necrosis of subcutaneous tissue
that may extend down to, but not through, underlying fascia. |
| Grade 4 |
Deep ulcer |
Extensive
destruction, tissue necrosis, or damage to muscle, bone, or
supporting structures with or without full thickness skin loss. |
The diagnosis
of the existence of a pressure ulcer is more difficult than one
commonly assumes. There is often confusion between a pressure ulcer
and a lesion that is caused by the presence of moisture, for instance
because of incontinence of urine and/or faeces. The differentiation
between the two is of clinical importance since prevention and treatment
strategies differ largely and the consequences of the outcome for
the patient are of imminent importance. This statement on pressure
ulcer classification is limited to the differentiation between pressure
ulcers and moisture lesions. Obviously there are numerous other
lesions that might be misclassified as a pressure ulcer (e.g., leg
ulcer, diabetic foot). Previous experience has shown that, due to
the location of moisture lesions, these lesions are the ones most
often misclassified as pressure ulcers (2–3). Wound related
characteristics (causes, location, shape, depth, edges, and colour)
and patient related characteristics are helpful to make a differentiation
between a pressure ulcer and a moisture lesion (see Tables 2 and
3).
Table 2: Wound Related
Characteristics
| |
Pressure
Ulcer |
Moisture
Lesion |
Remarks |
| Causes |
Pressure
and/or shear must
be present. |
Moisture
must be present (e.g. shining, wet skin caused by urinary incontinence
or diarrhoea) |
If moisture
and pressure/shear are simultaneously present, the lesion could
be a pressure ulcer as well as a moisture lesion (combined lesion). |
| Location |
A wound
not over a bony prominence is unlikely to be a pressure ulcer. |
A moisture
lesion may occur over a bony prominence. However, pressure and
shear should be excluded as causes, and moisture should be present.
A combination of moisture and friction may cause moisture lesions
in skin folds. A lesion that is limited to the anal cleft only
and has a linear shape is no pressure ulcer and is likely to
be a moisture lesion. Peri-anal redness / skin irritation is
most likely to be a moisture lesion due to faeces. |
It is possible
to develop a pressure ulcer where soft tissue is compressed
(e.g., by a nutrition tube, nasal oxygen tube, urinary catheter).
Wounds in skin folds of bariatric patients may be caused by
a combination of friction, moisture and pressure. Bones may
be more prominent where there is significant tissue loss (weight
loss). |
| Shape |
If the
lesion is limited to one spot, it is likely to be a pressure
ulcer. Circular wounds or wounds with a regular shape are most
likely pressure ulcers, however, the possibility of friction
injury has to be excluded. |
Diffuse,
different superficial spots are more likely to be moisture lesions.
In a kissing ulcer (copy lesion) at least one of the wounds
is most likely caused by moisture (urine, faeces, transpiration
or wound exudate). |
Irregular
wound shapes are often present in a combined lesion (pressure
ulcer and moisture lesion). Friction on the heels may also cause
a circular lesion with full thickness skin loss. The distinction
between a friction lesion and a pressure ulcer should be made
based on history and observation. |
| Depth |
Partial
thickness skin loss is present when only the top layer of the
skin is damaged (grade 2). In full thickness skin loss, all
skin layers are damaged (grade 3 or 4). If there is a full thickness
skin loss and the muscular layer is intact, the lesion is a
grade 3 pressure ulcer. If the muscular layer is not intact,
the lesion should be diagnosed as a grade 4 pressure ulcer.
|
Moisture
lesions are superficial (partial thickness skin loss). In cases
where the moisture lesion gets infected, the depth and extent
of the lesion can be enlarged/ deepened extensively. |
An
abrasion is caused by friction. If friction is exerted on a
moisture lesion, this will result in superficial skin loss in
which skin fragments are torn and jagged. |
| Necrosis |
A
black necrotic scab on a bony prominence is a pressure ulcer
grade 3 or 4. If there is no or limited muscular mass underlying
the necrosis, the lesion is a pressure ulcer grade 4. Necrosis
can also be considered present at the heel when the skin is
intact and a black/blue shimmer is visible under the skin (the
lesion will most likely evolve into a necrotic escar). |
There is no necrosis in a moisture lesion. |
Necrosis
starts without a sharp edge, but evolves into sharp edges. Necrosis
softens up and changes colour (e.g. blue, brown, yellow, grey),
but is never superficial. Distinction should be made between
a black necrotic scab and a dried up blood blister. |
| Edges |
If
the edges are distinct, the
lesion is most likely to be a pressure ulcer. Wounds with raised
and thickened edges are old wounds. |
Moisture lesions often have diffuse or irregular edges. |
Jagged edges are seen in moisture lesions that have been exposed
to friction. |
| Colour |
Red
skin:
If redness is non-blanchable, this is most likely a pressure
ulcer grade 1. For people with darkly pigmented skin persistent
redness may manifest as blue or purple.
Red in wound bed:
If there is red tissue in the wound bed, the wound is either
a grade 2, a grade 3 or a grade 4 pressure ulcer with granulation
tissue in wound bed;
Yellow in wound bed:
Softened necrosis is yellow and not superficial; it is either
a grade 3 or a grade 4 pressure ulcer. Slough is a creamy,
thin and superficial layer; it is a grade 3 or a grade 4 pressure
ulcer.
Black in the wound bed:
Black necrotic tissue in the wound
bed indicates a pressure ulcer grade 3 or grade 4. |
Red
skin:
If the redness is not uniformly distributed, the lesion is likely
to be a moisture lesion
Pink or white surrounding skin:
maceration due to moisture. |
Red
skin:
If the skin (or lesion) is red and dry or red with a white sheen,
it could be a. o. a fungal infection or intertrigo. This is
often observed in the anal cleft.
Green in wound bed:
Infection.
Be aware that zinc oxide ointments may result in whitened skin.
Whilst eosine is not recommended, it is still used in some areas.
It will turn the skin red/brown and obstruct the observation
of the skin. |
Table 3: Patient Related Characteristics
| Try
to find out the causes of the lesion: |
Check
the (wound) history in the patient record
• If the lesion commenced as a large and deep lesion,
it is unlikely that it is a moisture lesion.
• If the lesion developed after a long period of pressure
and/or shear (e.g., surgery, emergency department, radiology),
even if the pressure and/or shear are not currently present,
it is likely the lesion is a pressure ulcer. |
Which
measures are taken/ what care is provided?
• Superficial linear lesions are often caused by removing
sticking plaster and are neither pressure ulcers nor moisture
lesions.
• If the pressure ulcer does not improve despite pressure
relieving measures and suitable dressings for more than 7 to
10 days, and moisture is present, consider the possibility that
the lesion is a moisture lesion.
• If the moisture lesion does not improve despite the
use of skin barrier products and incontinence/moisture management
for more than two days, and pressure and/or shear is present,
consider the possibility that the lesion is a pressure ulcer.
Exclude the possibility of contact sensitivity (e.g., latex
allergy). A dermatological consultation is recommended when
in doubt about the diagnosis of contact allergy. |
What
is the skin condition at the different pressure points?
• If a pressure ulcer is present at another pressure point,
it is likely this new lesion is also a pressure ulcer |
Check
whether the movements, transfers and position (changes) of the
patient, may have caused the lesion.
• If the affected area is a pressure point, a pressure
ulcer is likely.
• If the affected area is not a pressure point, it is
unlikely that the lesion is a pressure ulcer.
• If friction is exerted on a moisture lesion, this will
result in superficial skin loss in which skin fragments are
torn and jagged
• Continuous friction causes abrasions
• If shear deforms the superficial and deeper tissue layers,
a pressure ulcer may be the result.
• If a lesion occurs on the heel, check if the lesion
was caused by:
a) pressure and/or shear => likely a pressure ulcer,
b) movement/transfer/shoes => likely a friction lesion/abrasion
not pressure ulcer. |
If
a patient is incontinent, consider whether the lesion is a moisture
lesion or not.
• If skin barrier products are used in patients who are
incontinent, then the chance that a new lesion is a moisture
lesion is limited.
• If diapers or incontinence pads are often saturated,
consider possibility of a moisture lesion. |
Exclude
other possible causes.
• Sometimes it can be difficult to differentiate between
a moisture lesion and an infection (e.g., candida intertrigo),
also characterised by irregular edges and satellite lesions
(‘islands in front of the coastline’). In these
cases the clinical picture (fever, leucocytosis) should differentiate
from moisture lesions.
• Other dermatological conditions should be considered
when in doubt about the diagnosis of pressure ulcer or moisture
lesion. A dermatological consultation is then recommended. |
| Additional
parameters |
Texture
of the skin
• Dead tissue feels dry / leathery and not pliable. |
Temperature
of the skin
• Compare the temperature of the skin at the pressure
point with the temperature of the surrounding skin.
This may also be an indicator for detecting grade 1 pressure
ulcer in patients with a darkly pigmented skin.
a) If the temperature is higher than that of the surrounding
skin, hyperaemia is present and the lesion is recent.
b) If the temperature is lower than that of the surrounding
skin, the blood flow is limited and the lesion is not recent. |
Pain
• Pain is described in 37% to 87% of the patients with
pressure ulcers.4
Therefore pain is not a discriminating characteristic for pressure
ulcers.
• Pain is caused:
a) by irritation of the sensory nerve endings in and around
the ulcer;
b) when the wound is debrided;
c) when aids are applied too tightly (e.g., tubes, drains);
d) when dressings rub against the surface of the wound;
e) when dressings that stick to the wound surface are removed.
• Patients with pressure ulcers experience both acute
and chronic pain and describe the sensation as burning, stinging,
sharp, stabbing and tingling. |
References
1 European Pressure Ulcer Advisory Panel (1999)
Guidelines on treatment of pressure ulcers. EPUAP Review
1, 31–33.
2 Defloor, T. De Bacquer, D.D., and Grypdonck,
M.H. (2005). The effect of a pressure reducing mattress on turning
intervals in geriatric patients at risk of developing pressure ulcers.
International Journal of Nursing Studies, 42(1): 37–46.
3 Defloor, T. and Schoonhoven, L. (08/13-07-2004)
Interrater and intrarater reliability of the EPUAP pressure ulcer
classification system. In (pp. 56). Paris: 2nd World Union of
Wound Healing Societies’ Meeting.
4 De Laat HEW, Scholte op Reimer WJM, and van Achterberg
T. (2005) Pressure ulcers: diagnostics and interventions aimed at
wound-related complaints: a review of the literature. Journal
of Clinical Nursing, 14: 464–472.
|
