Is There Such a Thing as “Reverse Staging” for Healing Bed Sores?

Question MarksA bed sore that properly heals will resist infection as the body restores the blood supply to the affected area. The bed sore will shrink and eventually vanish as the edges of the wound close and healthy tissues cover the exposed area. Reverse staging refers to the natural progression of a pressure ulcer from a more severe to a less severe stage as it heals. Not all physicians believe in reverse staging, however, as it may inaccurately assess the condition of the wound.

Four Stages of a Bed Sore Injury

Physicians categorize bed sore injuries into four main stages. A lower stage means a shallower ulcer. Stage one ulcers have the highest odds of successful recovery. Stage four ulcers, on the other hand, can come with life-threatening complications such as blood or bone infections. To diagnose reverse staging, a patient must first receive an official bed sore diagnosis and the stage of the original ulcer. The four stages are as follows:

  1. Stage one. A stage one pressure ulcer does not break the skin. It only affects the top layer of skin, or the epidermis. It presents as red, swollen, or warm skin that may cause the patient pain or itchiness. Skin with a stage one pressure sore may feel harder or softer than the surrounding skin. Turning the patient to relieve pressure will typically treat a stage one pressure sore in two to three days.
  2. Stage two. A stage two bed sore means the skin has torn or broken, forming an ulcer. It impacts the dermis, or second layer of skin. The skin may blister, fill with fluid, or ooze liquid or pus. The area around the sore may be red, warm, and tender. Treatment includes cleaning the wound with an antibacterial solution and wrapping it in moist gauze to help prevent infections.
  3. Stage three. In stage three, a bed sore has penetrated through the second layer of skin and into the fat tissues. A stage three bed sore creates a crater in the skin, and may show signs of infection. Some tissues may have died, and turned black or brown. The wound may exhibit pus, drainage, odor, or heat. Stage three pressure ulcers need one to four months to heal.
  4. Stage four. The most severe bed sore stage affects the underlying muscles and tendons. The crater will run deep, and may expose bone. These bed sores often have infections, and the tissues may appear black and have red edges, odors, and pus drainage. Stage four bed sores may require surgeries for proper healing. They could take months or even years to fully heal.

A physician will classify the stage of a pressure ulcer after removing necrotic tissues and examining the depth of tissue damage. In a bed sore that heals normally, the wound will progress from stage four to three, two, and then one. Stating that a bed sore has moved into a different stage, however, may not be the best practice for bed sore assessment.

Arguments Against Reverse Staging

Although the law mandates that long-term care facilities must use reverse staging, many believe it is an inaccurate assessment of the wound. Reverse staging can misclassify the extent of wound healing on the inside, even if the wound looks improved from the outside. A healing stage four ulcer, for example, will have a great deal of scar tissue rather than original muscle and fat. Scar tissue does not have the same composition as tissue that never had a wound. Reverse staging does not accurately represent what is physiologically happening in the ulcer. Physicians may underestimate the amount of healing the interior of the wound has undergone.

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