1. Salcido, Richard MD, EdD

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During a recent National Pressure Ulcer Advisory Panel (NPUAP) "Staging Consensus Conference" in Chicago, Illinois, the NPUAP released a monumental change to the taxonomy of pressure ulcers that essentially abandons the use of the time-honored nomenclature that used "pressure ulcers" as the basis for its classification system. In the new regimen, the term "pressure ulcers" will be replaced by a taxonomic nomenclature referred to as "pressure injury."1

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The new taxonomy is described as "injured intact skin, and the other stages beyond are described as open ulcers." According to the NPUAP,1,2 the previous staging system led to "confusion because the definitions for each of the "injury" stages were referred to as "pressure ulcers."1,2


The ostensible change in the new staging terminology provides a more accurate description of pressure injuries to both intact and ulcerated skin.1,2 The specific aim for this change in the staging taxonomy was to disambiguate the conflation caused by the term "Stage 1" and "deep tissue injury."


Additional terms presented at the NPUAP meeting included pressure injuries at the human-machine interface, such as "medical device-related stress injury" and "mucosal membrane pressure injury." Although these types of injuries are not considered iatrogenic, the devices should be prescribed and monitored, and a program instituted to prevent pressure injury.


Other significant changes include shifts in the ordinal classification for the grades of damage that are labeled in Arabic numbers, rather than Roman numerals.1,2 Although the NPUAP update is a step in the right direction, it is a work in progress. As such, according to the European Pressure Ulcer Advisory Panel (EPUAP) website,3 they are discussing the NPUAP change in terminology; albeit, they have not made a decision whether to adopt the "pressure injury" term and the new pressure ulcer classification. Follow the EPUAP website for updates on this topic.3


It is my belief that the NPUAP's new staging system aligns with global definitions of pressure ulcers (injuries). However, significant questions remain, and chief among them, the terms "Caucasian" and "non-Caucasian" skin used in the illustrations needs further review. The National Library of Medicine (NLM) often used the term "Caucasian" to refer to a race in the past.4 However, it later discontinued such usage for the narrower geographical term "European," which traditionally applied only to a subset of Caucasoids (Caucasians).4 According to the NLM technical bulletin, Caucasoid as a race classification was replaced by the European Continental Ancestry Group.4 By way of example, one can be considered white and Caucasian European if he/she emanates from the Continental Ancestry Group, even if he/she has a dark skin tone. The Negroid race originated from the African Continental Ancestry Group, and American blacks are considered African Americans.4 The point is, using the new NPAUP suggested terminology and illustrations of "healthy skin Caucasian" and "healthy skin non-Caucasian"; and likewise, using Stage 1 pressure injury "non-Caucasian" and "Caucasian" is not as straightforward as the new standards imply.1-5


The new NPUAP classifications are asking bedside practitioners to assess the skin using outdated anthropologic constructs to determine a patient's race. Moreover, there is a lack of clinical correlation between the racial origins of peoples of the world and their skin color. Instead of focusing on race and origin, we should note the skin only as light skin- or dark skin-toned individuals.5 Our wound care clinicians can practice expert care without being encumbered by anthropologic constructs that are becoming less important because of evolving global migrations.




1. National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory Panel announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. Last accessed May 26, 2016. [Context Link]


2. National Pressure Ulcer Advisory Panel. Pressure injury staging illustrations. Last accessed May 26, 2016. [Context Link]


3. European Pressure Ulcer Advisory Panel. EPUAP position on "pressure injury" terminology change. Last accessed May 26, 2016. [Context Link]


4. National Library of Medicine. MEDLINE data changes-2004. Last accessed May 26, 2016. [Context Link]


5. McCreath HE, Bates-Jensen BM, Nakagami G, et al. Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development [published online ahead of print April 8, 2016]. J Adv Nurs 2016 [Context Link]