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Words on Wounds
A forum to discuss the latest news and ideas in skin and wound care.
Thursday, June 30, 2011
Pressure Ulcer: Unanswered Questions

The number of people affected by pressure ulcers is growing across a continuum of healthcare settings. However, the conceptualization of pressure ulcers continues to spark many debates in the practice community as new insight into the development of pressure ulcers emerges. As the name implies, a pressure ulcer is caused by pressure, but it is often confused with other skin conditions, such as moisture-associated skin damage and incontinence-related dermatitis, skin tears, localized erythema due to inflammation, soft tissue infection, and even callused areas.

On the other hand, if pressure is the primary causative factor, should all plantar foot ulcers be considered pressure ulcers? The notion of deep tissue injury has also raised the question of whether pressure ulcers occur from inside-out, outside-in, or somewhere in the middle and then spread inward and outward. Perhaps there are different types of pressure ulcers precipitated by distinct mechanical forces (shear, friction, and/or pressure).

Furthermore, the current pressure ulcer classification systems are often misinterpreted, leading to the assumption that pressure ulcers always progress from Stage I to Stage IV. It is a conundrum to classify a healing pressure ulcer that is almost epithelialized when previous documentation and assessment is not available. The healing ulcer could be a healing Stage IV ulcer versus a healing Stage II ulcer. From a legal regulatory and reimbursement standpoint, there are heated debates whether pressure ulcers should be considered avoidable or preventable. Obviously, we are far from reaching a consensus but the discourse can be constructive providing momentum for further research and policy review.



Dr. Kevin Woo said:
Hi Melanie, Thank you for your question and it is an important one that often causes a certain degree of confusion among clinicians. By definition, Stage II pressure ulcers include ulcers with damage that only extends to the dermal layer, including "blisters." Although pressure may play a role, blisters are often caused by friction. When a blister is visible, tissue damage (friction or pressure) to the epidermis has occurred, already leading to the inflammatory response as evident by fluid in blisters. So, once a blister has occurred, it is classified as a Stage II pressure ulcer (of course implying that the blister is induced by pressure, friction, or shear) until the base is fully epithelialized. I hope this is helpful. --Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA
Melanie Bray said:
I have been examining definitions of stage II pressure ulcers and am wondering about differentiating between that and a "blister", (specifically one on the heel). This may or may not include callous formation. If the blistered area then breakdown and opens, would it then be re-classified as a pressure ulcer?
About the Author

Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA
Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA, is Assistant Professor, School of Nursing, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada; Adjunct Research Professor, MClSc Program, School of Physical Therapy, and Faculty of Health Sciences, Western University, London, Ontario; Wound Care Consultant, West Park Healthcare Centre, Toronto, Ontario, and Clinical Web Editor, Advances in Skin & Wound Care.