United States Health Information Knowledgebase

 

Pressure Ulcer


Form ID: F10
Form Name: Pressure Ulcer
Version: 1.2
Form Short Name: Pressure Ulcer
Synonym: PU
Definition: A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction which may be classified according to the following stages:
Stage/Category I: Intact skin with non-blanchable erythema of a localized area, usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. This may indicate an "at risk" individual.
Stage/Category II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister or sero-sanginous-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration or excoriation.
Stage/Category III: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Some slough may be present. It may include undermining and tunneling. Further description: The depth of a Category III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue, and Category III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category III pressure ulcers. Bone/tendon is not visible or directly palpable
Stage/Category IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. It often includes undermining and tunneling. Further description: The depth of a Category IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue, and these ulcers can be shallow. Category IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis likely to occur. Exposed bone/muscle is visible or directly palpable.
Unstageable: Full thickness skin or tissue loss - depth unknown: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined, but it will be either a Category III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.
Suspected Deep Tissue Injury - depth unknown: Purple or maroon localized area of discoloured, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Further description: The area may be preceded by tissue that is painful, firm, mushy, boggy, or warmer or cooler than adjacent tissue. Deep tissue injury 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 treatment.
Setting: Hospitals, including outpatient pharmacies and outpatient departments located within the hospital
Language: U.S. English
Guide For Use: Use this form to report a pressure ulcer or suspected deep tissue injury that was 1) not present on admission (i.e., newly-developed), or 2) worsened during the patient's stay. Report only an event that occurred prior to patient discharge. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF). Exclude mucosal, arterial, or venous ulcers, diabetic foot ulcers, and ulcers in patients receiving palliative care. If a pressure ulcer is reported at a certain stage and gets worse before improvement, please do not complete a new Pressure Ulcer Event Report. Instead, edit the existing event report to reflect the new stage and submit this report.
Comments: None defined at this time
Description Of Change: Not Applicable
Data Element ID Sort Data Element Name Sort Question Number Sort Version Sort Effective Date Sort Until Date Sort
DE408 Most advanced stage of pressure ulcer or sDTI reported 1 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE411 sDTI status on admission 2 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE414 Status of Stage 3, 4, or unstageable pressure ulcer on admission 3 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE420 Admission skin inspection documented 4 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE423 Timing of first pressure ulcer risk assessment 5 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE426 Type of pressure ulcer risk assessment 6 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE429 Documented increased risk for pressure ulcer 7 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE432 Pressure ulcer prevention intervention 8 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE435 Type of pressure ulcer intervention(s) used 9 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE438 Device involvement in pressure ulcer 10 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE441 Type of device involved with pressure ulcer 11 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE444 Type of tube that contributed to pressure ulcer 12 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE447 Development of secondary morbidity during stay 13 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE450 Secondary morbidity attributed to pressure ulcer or sDTI 14 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
Effective Date: 04/01/2012
Until Date: - -
Update Date: 04/24/2013
Submitting Organization: Agency for Healthcare Research and Quality (AHRQ)
Date of Submission: - -
Responsible Organization: Agency for Healthcare Research and Quality (AHRQ)
Creator: Amy Helwig, MD, MS
Data Steward: Agency for Healthcare Research and Quality
References: Not Applicable
Administrative Status: Final
Administrative Status Date: 01/24/2014
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