Understanding pressure ulcer staging

Episode 135
Categories: Bedsores

While pressure ulcers remain a common problem in long term care facilities across the country, we only seem to be inching closer to a more effective standard for diagnosing. On this week’s episode, nursing home abuse attorneys Rob Schenk and Will Smith welcome Martha Kelso @MarthaRKelso of Wound Care Plus to discuss current methods of  staging a pressure ulcer and the issues that come with each.

Schenk: Hello out there and welcome back to the Nursing Home Abuse Podcast. My name is Rob Schenk and I will be your host for this episode. We’re going to be talking about pressure ulcers, diagnosing pressure ulcers, the different stages that pressure ulcers go through and some of the methods in which we diagnose and treat pressure ulcers.

And the reason why I wanted to have an episode talking about pressure ulcers at this time is that every year, there is what is Pressure Ulcer Awareness Day, and Pressure Ulcer Awareness Day, if I’m not incorrect in looking at my calendar, is going to be November 21, so that’s why I feel like this topic is timely. So just want to bring awareness to the issue of pressure injuries, particularly in the nursing home setting.

But we’re not going to do that alone in this episode. It’s not just going to be me. We are going to have a special guest and that guest is Martha Kelso. And for long-time listeners of this podcast, you’ll know that Martha Kelso was our guest on the same topic back on Episode 118, where we talked about prevention of pressure ulcers in nursing homes, so we’re welcoming Martha back this week. But for those that missed that episode, we’re going to talk a little about her so you understand where she’s coming from.

Martha Kelso is the founder and chief executive officer of Wound Care Plus. As a visionary and entrepreneur in the field of mobile medicine, she has operated mobile wound care practices nationwide for many, many years. She enjoys educating on the art and science of wound healing and how practical solutions apply to healthcare professionals today. Kelso enjoys being a positive change in healthcare impacting clients suffering from wounds and skin issues of all kinds.

Kelso’s desire to make healthcare a better place for consumers motivated her desire to form and found Wound Care Plus. Early in her career, she was a wound care nurse in long-term care, and this past experience has committed Kelso to educate other fellow wound nurses on regulations and national standards of wound healing, thereby empowering the bedside nurse with tools and knowledge. And with that, we thank her so much for being here. Martha, welcome to the show.

Martha: Oh, thanks so much. It’s great coming back, Rob.

Schenk: Yes, ma’am. I just wanted to give you a quick shout-out because we, as I mentioned at the top of the show, we had you on Episode 118 about preventing pressure ulcers in nursing homes, and I have to say, I think that the stats are in and I think that has to be our highest rated show – well not rated in terms of reviews, but I don’t know how to say this in podcast terms, but highest-watched or downloaded, whatever the nomenclature is, but you helped make a fantastic success in terms of viewership and listenership, and I think it’s because you really brought the knowledge and shared it with your audience. So we really appreciate that and that’s one of the main reasons we wanted to get you back talking about pressure ulcers because it was such a great resource for people.

Martha: Yeah, I’m glad to hear that the education is getting out there too. I think it’s so important. Knowledge is power and whether you’re living with a wound or you’re having a loved one living with a wound, the more you know, the better off we all are.

Schenk: That’s exactly right. And that’s kind of where I want to focus on this episode, because last episode, we had you on there, I think we just talked about the basic prevention and interventions with pressure ulcers, but I really want to kind of get a little bit deeper into understanding development of pressure ulcers, and from a basic, almost like a health provider, healthcare professional standpoint of why these particular types of wounds can be a different proposition.

So for the audience out there, if you want to know the basics of pressure ulcers, what they are, that kind of thing, please be sure to check out that previous episode because we kind of spend the first five or six minutes talking about that. So if you need a refresher on what type of injury a pressure ulcer is, I would encourage you to do that. So we’re going to kind of skip that process and we’re going to go into a little more detail about this.

So the first question, Martha, that I have for you is why is a pressure ulcer more difficult to diagnose? Like why is this – it seems like it’s intuitive, like it’s a pressure ulcer, but maybe not. So what makes it hard to know that it’s in fact a pressure ulcer?

Why is it difficult to know if an ulcer is from pressure?

Martha: Well there’s no study in the world that – and when I say study, I mean a test, a diagnostic test that we can order, in the world today that proves hands-down that a wound is a pressure ulcer. And pressure ulcers mimic so many other wound types. So for example, if you have an arterial ulcer on your ankle, it looks identical to a pressure ulcer, and that’s the challenge. Marjolin’s ulcers look identical to a pressure ulcer. Marjolin’s ulcers, I can confirm on biopsy. There’s a test I can order proving that it is a Marjolin’s ulcer. There is not a test I can order proving that a wound is a pressure ulcer, and the current national guidelines, national standards state that pressure ulcers are exclusion of other diseases.

Schenk: So you basically – if there is what you suspect is a pressure ulcer, I guess is it a matter you want to rule other things out first and what’s left is it’s likely a pressure ulcer? Is that kind of where we’re at?

How do we determine whether an ulcer is from pressure?

Martha: That’s correct. I would add the word “unless” – unless you actually saw pressure happen with your own eyes. So if you walk into a room and their heel is sitting on something and you move their heel and there’s that indent or the wound is clearly from what the heel was sitting on, that’s pressure hands down. You’re not guessing. You saw it happen.

Schenk: That makes sense and I guess the difference between those types of ulcers would be more of a concern based on if it’s on a limb versus if you have one on the coccyx, the sacrum. I mean wouldn’t that necessarily mean you’re definitely looking at pressure at that point or is it still you need to rule things out?

Martha: Yes, again, great question. A Marjolin’s ulcer isn’t going to occur in the elderly. It is going to occur in the coccyx or the sacral area.

Schenk: That makes sense.

Martha: A radiation necrosis wound, the further you go out from radiation, so let’s say that you had your prostate radiated in the 1980s, the further you go out from the radiation, the greater the chance of skin destruction from the isotopes. So if you had prostate radiation, it’s usually through the coccyx area, so radiation necrosis would occur in that area.

Schenk: That makes sense. So I guess then from a broad standpoint then, can you just talk about from a health standpoint or a medical standpoint kind of what the basic differences are between these different types of ulcers developing if not from pressure?

What are different types of ulcers other than pressure?

Martha: So arterial ulcers develop from lack of blood flow or lack of oxygenation. There’s not enough nutrients or oxygen to keep the skin healthy because they’re not getting enough profusion to the area, where pressure is caused from prolonged intense pressure occurring over that tissue area, that area of tissue or bone, that pressure is preventing the blood flow from getting to the tissue, so therefore the tissue dies and you have tissue necrosis.

Schenk: Got you.

Martha: Both of them are from tissue deaths, but it’s the cause of the tissue death or the underlying etiology that determines how you diagnose the wound.

Schenk: Is it possible to have – and you’re saying arterial ulcer, is that the same as a vascular ulcer?

Martha: It can be, but you can have vasculitis that’s actually an autoimmune disorder. So arterial disease is from the absence of blood flow. People who have had strokes or heart attacks have known arterial disease throughout their entire body. But you can also have arterial inclusion, like an artery that’s included that’s also an arterial wound. So sometimes the cause of the arterial disease could be different causes. The cause of your arterial wound could be from different causes.

Schenk: Understood. So that’s going to obviously determine the course of treatment knowing the differences between these types of ulcers and the culprits.

Do different ulcers have different healing times? Can some ulcers not be healed?

Martha: And whether or not the wound is healable. So if you have a 90 percent inclusion say from the popliteal artery down and they’re a surgical candidate, chances are we get them out for surgery, get the inclusion opened up and the wound will go on and heal. But if they’re not a surgical candidate, the wound is not going to heal. As a matter of fact, it will get worse and they will probably develop more wounds because of the lack of blood flow, in which case that’s a palliative wound or a possibly a hospice candidate.

How can we determine if an ulcer is arterial or from pressure?

Schenk: Sure. So then how are you ruling out the arterial ulcer? What’s the process by which you would do that?

Martha: The fun thing is we’re living in the millennium, right? And so we don’t have to do 1980 wound care anymore, which is awesome. So we have numerous studies out there we can order to prove that a wound has arterial disease, so arterial ultrasound would be one of them. The great thing is it’s a non-invasive study, rarely, rarely painful. You can also do an ankle brachial index, also known as an ABI. We can also do an endovascular surgeon and have an arteriogram performed, so an arterial mapping, a potential study showing where the inclusion is and are there other inclusions. So I would say that we have options out there on differential diagnostic studies to order to determine whether that wound is arterial or not.

Schenk: I would say this. Well my sister would take issue with the fact that we’re not living in the ‘80s. She watches at least two or three episodes of “Golden Girls” every night. She’s got the – not laser disc, that would be the ‘80s version – she’s got the Blu-ray, that’s the word I’m looking for, of “Golden Girls.” Anyways, I digress.

Okay, so Martha, then why is it that you think that – and maybe I’m putting words in your mouth, but I feel like from our last conversation, it was your opinion that oftentimes, well maybe not oftentimes, but sometimes there’s a tendency to over-diagnose something as a pressure ulcer. Why is that then? What makes that the case?

Are pressure ulcers over diagnosed?

Martha: I think that we’re so tuned to the fact that if it’s over a bone, it must be pressure. And even as a young nurse early in my career, that’s what I was taught also, is if it’s over a bone, you call it pressure. You stage it. You list it as pressure. And oftentimes we’re relying on nurses to diagnose. Nurses are trained in differential diagnostics. That’s why you need physicians, nurse practitioners, physician’s assistants, but also people that are trained in the current standards of care, the current regulations, and then understanding that pressure ulcers mimic so many other wound types. And so we really want to get to the basics of how do we know what we’re treating.

Additionally, we also need to recognize that wounds are multi-factorial. There are always, almost always different factors playing into that wound, whether it’s nutrition, obesity. I try to list the word “non-compliant,” so you hear that a lot. Sometimes what we need to do to get the wound to heal or to prevent someone from developing new wounds, sometimes our patients are not willing to do that. That’s okay – your body. So sometimes we forget that our job is really to outline the options for the patient and it’s the patient’s job to choose an option. But I would say that more than 60 percent of the time, there’s mixed etiology playing that wound. They may be arterial and diabetic. They may be diabetic and have venous disease. They may have malnutrition and diabetes.

Schenk: You mentioned, and this might be a good segue here, you mentioned the word “staging” in that, in other words the ulcer, by most standards today, goes through a process by which it goes from stage one all the way to stage four, or depending, it could be on stage… Can you briefly kind of describe the stages of a bedsore and kind of talk about whether or not that’s actually an appropriate way to monitor them and keep track of them?

What are pressure ulcer stages?

Martha: Well that’s a loaded question. That’s interesting because there’s some pointed debates going on in the national realm of whether or not the staging scale is old and outdated and whether it is appropriate to even use the staging scale to currently stage pressure ulcers. The school of thought originally when the pressure ulcer scale was developed was that wounds develop from the outside in, and we know that that’s not always the case. Sometimes wounds are developing from the inside out, not related to neglect. Sometimes it is a deep tissue injury that begins at the level of the bone because the patient’s body is failing and therefore it erodes from the inside out instead of an external cause or something that happened laying on an object for too long. That’s inside out of course.

And the other challenge is the staging scale is not the same across the healthcare continuum. So home health nurses have their own staging scaleHospitals have their own staging scale. Nursing homes have a different staging scale. And so it becomes very complex. I can describe the nursing home staging scale if that’s what you would like because that is different than the National Pressure Ulcer Advisory Panel staging scale. They’re not the same, just to be clear.

Schenk: Sure. Yes, let’s kind of go into that a little bit with the nursing home and then we can talk about the NAP.

Martha: Okay, so in the nursing home, a stage one is an area that does not blanch, and when I think of a blanch, what I mean is does it blanch after a period of time? And so we talk about you get sleepy in the middle of the day and you fall asleep on your desk at work, if you raise yourself up, you would have a line probably on your face from laying too long. But within 30 minutes to an hour, that line would disappear. That’s a normal human phenomenon. That’s not a stage one pressure ulcer. That’s something that happens to all of us, even when we were children. So stage one pressure ulcer is non-blanchable and it does not blanch after a period of time, 30 minutes to an hour. So there’s no break in the skin, which means there’s no drainage. It will not have a purple area around it. It will not have bruising around it. It will simply be pink or red that’s not blanching or not blanchable caused from pressure.

Stage two is partial thickness. CMS came out with new guidance with long-term on November 2013 with what’s known as the Mega-Rule update and it really clearly says wounds caused by pressure, you may not have granulation tissue, you may not have slough and you may not have eschar in the wound. That would be a full thickness. So stage two is simply where the top layer or two of skin is missing and it’s not deeper than skin deep.

Stage three then is full thickness, so it’s down into granulation tissue. It’s missing the top layer and the second layer of skin, but it’s not down into muscle, tendon, bone, ligament. It might have some slough, but the slough does not obscure the base of the wound therefore obscuring the true depth of the wound. Sometimes they have an epibole or known as a rolled edge. In partial thickness wounds, you will not have a rolled edge.

In a stage four then, that’s full thickness that may be down to bone, tendon, muscle, or you may be able to directly palpate bone, tendon, muscle. That would also be a stage four. It might have an epibole, sinus tract, underlining.

An unstageable wound is when you cannot see the true depth of the wound. So there’s slough or something is covering the deepest part of the wound. And then your deep tissue injury is where there’s an injury that occurs at the level of the bone or muscle, very deep, and it may erode or open up, but it typically will have a heralding sign. There can be purple around the wound, something like that.

One more thought – there are four places on the body where subcutaneous tissue does not exist, therefore stage three does not exist, and that’s the ankle, the nose, the ear and then the occiput, the back of the head.

Schenk: Got you. And how does that staging model differ from the National Pressure Ulcer Advisory Panel?

How does the National Pressure Ulcer Advisory Panel stage pressure ulcers?

Martha: Yeah, so National Pressure Ulcer Advisory Panel issued guidance in an update in the most recent years, but because they’re an advisory panel, they are not the federal government, the Centers for Medicare and Medicaid, CMS issued direction to all of their entities, so long-term care, for example, CMS issued in the REI or the NDS manual that they are CMS and that everyone who is quoting wounds in long-term care must stage based on the REI manual, not on the NPUAP staging criteria. Same with long-term care hospitals, they must follow the staging criteria set by CMS, not by NPUAP. And so there are differences and nuances based on the definitions of the stage.

Schenk: Go ahead.

Martha: I was going to say, it might be prudent because there are so many different staging criteria across the continuum, it might be prudent to list those links, maybe on your website.

Schenk: Yes, go ahead.

Martha: I’ll send the links to those.

Schenk: Absolutely, we’ll put those up on the screen and I’ll put those in the show notes. Just email those to me a little later. I’ll make sure they get put on.

Martha: Okay.

Is there uniformity in pressure ulcer staging and diagnosing?

Schenk: That actually makes a good question for me is why do you think it’s so hard to have, or so difficult, to have uniformity between staging models and between the different types of facilities? Why does acute care need a different model than long-term care?

Martha: I wish I had the answer for that because it sometimes keeps me up at night. I find it very frustration as my company works, of course, across the continuum, so it’s very challenging to remember to use different staging criteria based on where you are. So if I was speaking to a loved or a relative, what I would say is pay attention to the wound measurement. Pay attention to the description of the wound, because in my opinion, it’s actually more important than the staging. So if we have a wound that has 80 percent healthy tissue this week and the next week, 50 percent healthy tissue, the wound has deteriorated or has gone backwards, or if it has any percent healthy tissue this week and 100 percent healthy tissue next week, now we’re cheering. We’re moving in the right direction. Because the other challenge is we don’t backstage a wound. Once a wound is a stage three, it’s always a stage three even if it’s getting better. So oftentimes that terminology is not the first thing I pay attention to. Is the drainage better? Is the pain better? Is there odor? Is the drainage green or is the drainage clear colored? So that’s what I would say about the staging criteria. The number isn’t necessarily the most important thing. It’s what’s happening with the wound that’s the most important.

Schenk: Right. And why do you think that is? What’s the problem in correlating the number to actually what’s going on because we have clients obviously that call us and say, “It’s a stage three or stage four,” and they’re upset and I look and it doesn’t look bad and they recover easily from it, so either it wasn’t a stage three or stage four or there’s an issue with the staging model. Why is there a problem in correlating those two things?

Is the current staging model helpful?

Martha: Well number one, I think confusion, but number two, the staging criteria is somewhat complicated. Additionally, we’re asking people top stage wounds based on level of tissue destruction, but they don’t always understand what they’re looking at. They often claim a nurse may call something bone when it’s in fact a joint capsule. They may refer to something as a tendon when it’s actually a ligament. And so nurses, unless they’ve actually been through surgical training and they’ve actually seen some of those structures in real life, sometimes we don’t know what we’re looking at but we’re expected to call it something. I don’t know if that makes sense.

Schenk: No, it does. And I think it makes sense – I guess that’s why in my experience, oftentimes the only descriptions that we get are just the measurements, because people really don’t know what these terms mean – granulated, partial thickness, full thickness – they just are like, “Okay, this is above my pay grade. It’s 5 cm by 6 cm by 1 cm, and I just let the doctor know.”

Martha: And some of the expert cases that I hear as expert witness, I have to tell you oftentimes doctors and nurse practitioners, even at the hospital, are not listing length, width and depth, and it’s one of the biggest red flags I have, because wounds are three dimensional. Wounds are always length, width and depth, always.

Schenk: Correct.

Martha: And so I often see things mislabeled, mis-quantified, and not just from our bedside nurses, sometimes by our doctors, nurse practitioners, physician’s assistants. Sometimes even the LPN, I see things that are mislabeled or misrepresented, and it’s a challenge across. You know, when I went to my RN and my LPN programs, there was no wound care training in my programs.

Schenk: That’s amazing. I mean pressure ulcers themselves, at least in my experience, are so common that that would be strange for them to have no training in that. That’s amazing.

Martha: There was no course. And so a lot of what I’ve learned over the last 27 years in my career has been on the job training or finding someone that was willing to be my mentor who really understood it, was willing to put up with my montage of questioning – “Why? Why? Why?” – healthcare’s broken in and of itself so we’ve got to give back to the industry and do educational forums and teach people ongoing, bring them into the fold say, “Let me show you something. I want to teach you about this.”

Schenk: That makes sense. Well this is something that we didn’t get into last episode, and again, our listeners are generally family members of nursing home residents. We’ve been using the term partial thickness and full thickness. Can you just basically describe what that means because that might be something they see on a chart and they have questions about what’s going on with their loved one?

What do full thickness and partial thickness pressure ulcers mean?

Martha: So partial thickness is the top layer or two of skin only, not deeper than skin deep. So to quantify that, a partial thickness wound, I want them to envision credit card thick or less or dime thick or less.

Schenk: That’s the partial thickness.

Martha: Mm-hmm – 0.1 centimeters or less, that’s all partial thickness. If everybody kind of looks at the backs of their hands and thinks, “Man, if I had a wound on the back of my hand that was deeper than credit card thickness,” you would already be down into deeper structures, right? So more than a credit card, more than dime thick is going to be your full thickness with more than your 0.1 centimeters. That’s full thickness. It simply means we’re through the skin down into deeper structures. And so kind of your easy button surgical wounds are always full thickness. You don’t pay a surgeon to kind of tease the top two layers of skin with your scalpel. An abscess is always full thickness. It’s always below the skin, usually into subacute tissue. If you have a biopsy or a skin graft, you know a dermatologist has removed a cancerous lesion, that’s full thickness always, hands down. So those are kind of my two descriptors for the two terms.

Schenk: And the reason why that’s the size of the dime, the thickness of a dime, that’s important is because that’s generally the difference between when you’re going through just the first layers of skin to actual tissue, and that’s important because it can be much more dangerous. Can you speak to that with regards to the concept that the wound actually starts from the bottom and moves towards the skin rather than the opposite?

Does a pressure ulcer start at the skin or below the skin?

Martha: Yeah, numerous wound types are from internal – they’re internal factors. So you think about somebody who’s maybe had blood clots and the blood clots have shot out throughout the body. That’s known as an embolic shower. That’s from an inside event working its way outside. A purpura, for example, is another skin symptom or disorder that always works inside out. And so a lot of injuries that occur towards tissue are from metabolic or medical issues. Even deep tissue injuries can be from medical issues where there – Kennedy Terminal Ulcer, for example, is from a medical issue. The body is failing, the organs are failing, we’re not using the tissue and the skin with good nutrition, hydration, blood flow, oxygenation, so the tissue death occurs, and because the tissue death is occurring, it starts eroding and eventually works its way out to where we can see it with our eyes.

Schenk: Right. So even though we’re talking about something that’s coming basically from inside the body, it starts – we don’t start to notice it until it’s on the skin essentially.

Martha: Correct.

Schenk: So just because you’re in that partial thickness doesn’t mean there’s not more things going on beneath the surface? Is that fair to say, I guess?

Martha: Well I wouldn’t agree with that.

Schenk: Okay.

Martha: I would say something that has symptoms, what I refer to as a heralding find, that purplish, you’ve already got a deep tissue. I would refer to that as full thickness because once that purplish color appears or has a bluish hue to it, it’s the body telling you there’s damage under here. We just haven’t opened up enough for you to see it. So for me, that’s a full thickness injury. I already know it’s deeper than skin deep. But partial thickness, if you’ve ever skinned your knee or gotten a rug burn, that’s the top layer or two of skin. That can take – I think about riding my bike and skinning my knee from riding my bike, and it bled at first and then it converted to a scab and then the scab eventually worked its way off, and in a young, healthy person, that took two to four weeks at the age of 7. And then you think about well how long would it have taken an elderly person? It can take up to 60 days for a partial thickness wound like a stage two to heal.

Sometimes I see people mislabel scabs as eschar. Eschar is full thickness by definition, has a different chemical makeup than a scab. It’s just something else to keep in mind. Sometimes we’re calling things eschar when it’s really a scab and sometimes we’re calling it scab when it’s really eschar. But scab is partial thickness. Eschar is full thickness.

Schenk: You know, you would think with so many residents, with so many patients, we would be moving closer to a uniform standard with all these things.

Martha: Mm-hmm.

Schenk: But Martha, thank you so much. This episode has flown by and I feel like a lot of the listeners’ questions have been answered, and again, you have been an excellent resource.

Martha: Sure.

Schenk: We so much appreciate you coming back on the show again. Thank you so much for your time.

Martha: Sure. I appreciate you having me back, Rob. I’ll talk to you soon. Thank you.

Schenk: Okay. We love to have Martha on the program. I would say after the second time, you’re a friend of the program is what I would say. But at any rate, again, you can tell that Martha is passionate about wound care, wound prevention, pressure ulcers. She’s really good at what she does and I would really highly recommend everybody check out Wound Care Plus online. Go check them out, read the website. It’s fantastic. It has a lot of information on there.

But again, I just want to remind everybody that Pressure Ulcer Awareness Day is coming up in the month of November, so keep that in mind. Put that on your calendar. Celebrate. And again, I would also say that you want to thank a veteran today. Today is obviously Veteran’s Day where we celebrate the sacrifices and ultimate sacrifices made by our military. So I just want to give a shout-out there. And also, November happens to be Alzheimer’s Awareness Month as well as National Caregivers Month, so a lot of stuff going on in November to celebrate and to be thankful for as well.

But at any rate, we appreciate you sticking through this long. Again, you can check out new episodes of the Nursing Home Abuse Podcast every other week – we are bi-monthly – on Monday mornings. Like and subscribe wherever you get your podcast from or you can watch the podcast in all of its glory on YouTube or on our website, which is NursingHomeAbusePodcast.com, that is NursingHomeAbusePodcast.com, and with that, we will see you next time.


  • What does pressure ulcer staging involve?
    • Pressure ulcer staging is a classification system used to describe the severity of pressure ulcers based on their depth and tissue involvement. It typically ranges from Stage I to Stage IV, with each stage indicating a different level of tissue damage. Understanding pressure ulcer staging is crucial for determining appropriate treatment and monitoring the healing process.
  • What factors are considered when determining the stage of a pressure ulcer?
    • Pressure ulcer staging is determined based on several factors, including the appearance of the wound, the depth of tissue damage, the presence of necrosis or eschar, and any associated symptoms such as pain or infection. Healthcare professionals assess these factors using standardized criteria to accurately classify the pressure ulcer and guide treatment decisions.
  • How can an Atlanta nursing home abuse attorney assist in cases involving pressure ulcers?
    • In cases where pressure ulcers occur as a result of nursing home neglect or abuse, an Atlanta nursing home abuse attorney can provide invaluable legal guidance and representation. These attorneys specialize in advocating for the rights of victims and holding negligent facilities accountable for their actions. If you suspect that a loved one has developed pressure ulcers due to nursing home neglect, consulting with an Atlanta nursing home abuse attorney can help you understand your legal options and pursue justice on behalf of your loved one.