This is a demonstration of a wound care physician explaining the proper staging of wounds using the MDS 3.0 staging convention. Japa Volchok, DO discusses the indications for each wound stage and explains why proper staging is important in documenting wounds. This demonstration is performed by a trained wound care physician for educational purposes only and should not be tried at home.
Understand Wound Care:
Wound Staging Demonstration Using MDS 3.0
Commentary: Japa Volchok, DO
Today we will be discussing the correct staging of a pressure ulcer as it pertains to MDS 3.0. MDS 3.0 is a staging convention used for the resident assessment. In the staging under MDS 3.0, there are some differences when compared to the older MDS 2.0 staging system and the more commonly known National Pressure Ulcer Advisory Panel staging. The MDS 3.0 staging convention uses four stages and an additional stage for an unstageable wound.
MDS 3.0 does not allow for reverse or back-staging of wounds.
The first stage is a stage one. This is an area of localized redness or erythema that is non-blanchable in intact skin.
In this demonstration, we will be showing the staging and measurement of a pressure ulcer using an artificial tissue model. The black dotted line shows the outline of a wound that when palpated and released does not show any change in the erythema. This is non-blanchable erythema consistent with a Stage 1 pressure ulcer. We would now measure the length of 3 centimeters by the width of 1.5 centimeters. It is intact epithelium and thus is a Stage 1 pressure ulcer with no measurable depth.
A Stage 2 pressure ulcer presents as a shallow ulcer with an area of open epidermis. There is no evidence of slough. A Stage 2 may also present as an intact or a ruptured blister. The blister may contain serum fluid-filled or a bloody fluid-filled blister. These are both staged as a Stage 2. If the underlying tissue with a blister shows evidence of deep tissue injury, or there is significant surrounding deep tissue injury, this should be staged as an unstageable secondary to deep tissue injury or DTI.
A Stage 3 pressure ulcer involves full thickness tissue loss including the epidermis and the dermis. It extends into the subcutaneous tissue but does not extend below the depth of the subcutaneous tissue. It may include tunneling or undermining as well as slough or necrotic tissue.
In this model we are demonstrating a Stage 2 on the right side of your screen and a Stage 3 on the left side of your screen. A Stage 2 pressure ulcer as seen on the right side of the screen involves loss of the epidermis and dermis. The Stage 3 pressure ulcer on the left side of your screen has involvement of deeper subcutaneous tissue and may also contain slough or necrotic tissue. Neither a Stage 2 as seen on the right side of your screen or a Stage 3 as seen on the left side of your screen extend into the fascia or muscle level. There is no involvement of bone or tendon.
A Stage 4 pressure ulcer involves full thickness tissue loss involving the epidermis, the dermis, the subcutaneous tissue and includes exposed muscle, fascia, bone or other underlying structures such as tendon. There may be undermining and tunneling. In addition, there may be areas of necrosis or eschar present in the wound bed.
In this model we have a Stage 4 pressure ulcer. You can tell from the depth of the wound that the wound is fairly deep and has extended to the level of muscle. These are muscle fibers running across the length of the wound. You can actually see those being held by the forceps. Just below the muscle fibers here is an area of exposed bone. A Stage 4 pressure ulcer involves fascia which is the layer immediately on top of the muscle, muscle itself or bone. Depending on the anatomic location on the body, the depth of the wound can vary dramatically. The subcutaneous tissue over an area such as the ankle and the lateral malleolus or on the hands can be fairly thin. An area such as the heel or the back can have significant subcutaneous tissue before you reach the level of muscle or fascia. The actual depth of the wound does not dictate the stage. Rather, the anatomic structures that are involved such as muscle, tendon or bone are what determines the stage of the wound. If the bed of this wound was obscured by necrotic tissue it would be staged as an unstageable. However, it is clear that there are muscle fibers present in the base of the wound as well as bone. This would then be categorized as a Stage 4 pressure ulcer.
This is a pressure ulcer that has necrotic tissue within the base of the wound. If we remove this completely, we see that the wound extends to the level of muscle fibers at the base of the wound. This would then be categorized after debridement as a Stage 4 pressure ulcer. Prior to debridement, the base of the wound was obscured and would be staged as an unstageable pressure ulcer.
The final category of staging under MDS 3.0 includes unstageable. There are several reasons that a wound may be unstageable. If there is suspected deep tissue injury, the wound should be staged as unstageable. This is because deep tissue injury often progresses to a much deeper extent than has originally appeared on the surface of the wound.
Other signs of DTI include color change, bogginess or tenderness.
This wound model has been developed to demonstrate a wound that has suspected deep tissue injury. The dotted line demarcates the edge of the wound. A correct wound assessment would involve measuring the length of 3.5 centimeters by the width of 2.5 centimeters. Staging this wound, if this were a heel ulcer, or a heel wound, or perhaps a wound on the sacrum on another anatomic site, where we can see an area of suspected deep tissue injury, this wound would be staged as unstageable secondary to DTI. This is the area of deep tissue injury.
Other reasons for staging a wound as unstageable include necrosis that covers the full extent of the wound or eschar that prevents visualization of the entire depth of the wound and identification of the anatomic structures.
Additionally, under MDS 3.0, there is a category unstageable secondary to a non-removable device. This would be appropriate for staging a wound that has been present under a cast that could not be removed or some other type of medical device that would not be normally removed. This does not include wounds that are covered by negative pressure. Unless the negative pressure device has explicitly been ordered not to be removed except by the licensed physician that ordered the device.
Under MDS 3.0, only pressure ulcers are staged with this convention. Pressure ulcers of a Stage 3 or 4 are measured and recorded in the MDS 3.0 resident assessment. In addition, diabetic foot ulcers are recorded under a separate category and are not staged using the aforementioned staging structure.