Tissue Viability Update
Following recommendations from the National Wound Care Strategy Partnership and in line with neighbouring trusts, DCHS will no longer be utilising “Unstageable” as a pressure ulcer.
Our categories will be as follows:
Mucosal membrane pressure ulcers
Mucosal membrane pressure ulcers occur in of the moist membranes that line the respiratory, gastrointestinal, and genitourinary tracts. They do not have the same anatomical structures as the skin; therefore, it is not possible to categorise them.
Suspected Deep Tissue Injury (SDTI)
Non blanching purple or maroon skin (light-toned skin) Discoloration (Dark skin tones). Skin can be firmer or soft (boggy) & warmer or cooler than surrounding tissues. Blood filled blister may also be present with dark wound bed.
Category 1 Pressure Ulcer / Non blanchable erythema
The ulcer appears as a defined area of persistent redness (erythema) in lightly pigmented skin tones, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues, without skin loss. The patient may report pain or discomfort over the area.
Category 2 Pressure Ulcer
Pressure ulcer with abrasion, blister, partial-thickness skin loss involving epidermis and or dermis.
Category 3 Pressure Ulcer
Pressure ulcer with full-thickness skin loss involving damage or necrosis of subcutaneous tissue. Undermining and tunnelling may occur, fascia, muscle, tendon, ligament, cartilage and or bone are not exposed.
Category 4 Pressure Ulcer
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage and/or bone in the ulcer. There is an increased risk of osteomyelitis.
The full recommendations can be found here.
Please note that as a trust we are not adopting these recommendations in their entirety and are keeping the SDTI category. These should continue to be reported via Datix.