The NPUAP further defines unstageable bed sores as “enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. 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.”  Obviously, an unstageable bed sore is considered to be severe and requires immediate medical attention.

Like most bed sores, Kennedy ulcers are believed to develop due to poor blood circulation that results from unrelieved pressure. However, Kennedy ulcers, differ from other bed sores because of:

• Rapid onset, a wound may go from a blister to stage 4 within hours
• The wounds tend to grow downward, as opposed to horizontally
• The wounds are most often located on the sacrum
• Wounds are almost exclusive to the elderly population
• The wounds are usually irregularly shaped, frequently described as pear shaped
• Death occurs quickly, many patients succumb to kennedy ulcers within 24-48 hours of their onset

The treatment options for people with Kennedy ulcers are limited due rapid development and progression. Consequently, most treatment for Kennedy uclers is focused on providing pain relief.

Resource:

Kennedy Terminal Ulcer LLC

The primary reason for not ‘reverse staging’ bed sores is that despite an outward appearence that a wound may be healing, bed sores simply do not completely heal. An advanced bed sore that appears to be healed, will still be unable to replace lost muscle, fat and skin that were lost due to the original wound. Therefore, reverse staging does not accurately characterize what is physiologically occurring in the bed sore.

Once a bed sore is categorized as a particular stage, it should always remain that stage– regardless of the outward appearance.

Source:

National Pressure Ulcer Advisory Panel

Stage 1- Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.

Stage 2- At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin’s deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

Stage 3- By the time a pressure ulcer reaches this stage, it has extended through all the skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater-like wound.

Stage 4- In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections. If you use a wheelchair, you’re most likely to develop a pressure sore on: Your tailbone or buttocks Your shoulder blades and spine The backs of your arms and legs where they rest against the chair When you’re bed-bound, pressure sores can occur in any of these areas: The back or sides of your head The rims of your ears Your shoulders or shoulder blades Your hip bones, lower back or tailbone The backs or sides of your knees, heels, ankles and toes.

Occasionally, a bed sore may be categorized as ‘unstageable‘.  Unstageable bed  sores are usually referred to as an extremely advanced wound where there is involvement of skin, muscle and bone.

Because of their tendency to develop deeply into the bodies layers of skin, fat, muscle and bone, tunneling bed sores can be particularly difficult to treat.  Many patients with tunneling bed sores require extensive medical treatment such as surgical debridement.  If left untreated, tunneling bed sores may be fatal.

Bed sores can form from one intense period of hard pressure, but usually occur when blood flow to skin, muscle, fat and tendons is restricted over longer periods of time.  Because the entire body relies upon a well oxygenated supply of blood, a reduction in blood supply causes the body to shut down, and those areas of the body die and wounds develop.

• Being bedridden or in a wheelchair
• Fragile skin
• Having a chronic condition, such as diabetes or vascular disease, that prevents areas of the body from receiving proper blood flow
• Inability to move certain parts of your body without assistance, such as after spinal or brain injury or if you have a neuromuscular disease (like multiple sclerosis)
• Malnourishment / dehydration
• Bladder or bowel incontinence
• Mental disability from conditions such as Alzheimer’s disease
• Older age

• Elbow
• Heels
• Hips
• Ankles
• Shoulders
• Buttocks
• Back
• Head

Nonetheless, bed sores can form anywhere unrelieved pressure builds on the body.  Staff in nursing homes and hospitals should be aware of the areas where bed sores are particularly susceptible to develop and pay special attention to those areas when conducting assessments of patients.