Deep Tissue Injury Research Articles

Suspected Deep Tissue Injury Profile

Advances in Skin & Wound Care: March 2014 - Volume 27 - Issue 3 - p 141-142 doi: 10.1097/01.ASW.0000444363.02184.d5

Suspected Deep Tissue Injury Profile

To enhance the learner's competence with knowledge of the results of research examining suspected deep tissue injury profiles. This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. After participating in this educational activity, the participant should be better able to: : The purpose of this study was to examine (1) the incidence of potential precipitating events of suspected deep tissue injuries (SDTIs) identified over a 7-day period prior to cutaneous manifestation, (2) physiological variables related to the formation of SDTIs, and (3) the time since precipitating events and the occurrence of the SDTI. A descriptive exploratory study. A retrospective chart review was conducted. A 348-bed community Magnet-redesignated hospital, Baptist Health Lexington Kentucky PARTICPANTS:: Eighty-five participants with SDTIs identified between January 2008 and March 2010. Precipitating events evaluated were tissue perfusion, surgery, transfers, mobility, and falls. Physiological variables included anticoagulation, albumin/prealbumin, hemoglobin, partial thromboplastin time, and hemoglobin A1c. Timeline differences between precipitating events and SDTI were measured. Precipitating events identified from most to least frequent were transfers = 67 (78.8%), tissue perfusion = 36 (42.5%), surgery = 33 (40.2%), mobility = 26 (30.9%), and falls = 14 (16.9%). Of the 85 charts reviewed, 69 of the charts met the criteria for timeline difference between precipitating event and SDTI manifestation. The range of days for precipitating events prior to SDTI manifestation was 1 to 5 days, an average of 2.41 (SD, 1.04) years. Meaningful physiological variables noted were anticoagulation 52 (61.2%), anemia (hemoglobin 6-9 g/dL) 53 (67.1%), and hemoglobin A1c less than 7.5 mmol/L 29 (74.4%). This exploratory pilot study evaluating patients with SDTI revealed the most common precipitating event was transfers. In addition, the physiological variables that appeared to contribute to the development of SDTIs were anticoagulation and anemia. The range of days for precipitating events prior to SDTI manifestation was 1 to 5 days, an average of 2.41 (SD, 1.04) days.

Heat transfer model for deep tissue injury: a step towards an early thermographic diagnostic capability.

BackgroundDeep tissue injury (DTI) is a class of serious lesions which develop in the deep tissue layers as a result of sustained tissue loading or pressure-induced ischemic injury. DTI lesions often do not become visible on the skin surface until the injury reaches an advanced stage, making their early detection a challenging task.TheoryEarly diagnosis leading to early treatment mitigates the progression of the lesion and remains one of the priorities in clinical care. The aim of the study is to relate changes in tissue temperature with key physiological changes occurring at the tissue level to develop criteria for the detection of incipient DTIs.MethodSkin surface temperature distributions of the damaged tissue were analyzed using a multilayer tissue model. Thermal response of the skin surface to a cooling stress, was computed for deep tissue inflammation and deep tissue ischemia, and then compared with computed skin temperature of healthy tissue.ResultsFor a deep lesion situated in muscle and fat layers, measurable skin temperature differences were observed within the first five minutes of thermal recovery period including temperature increases between 0.25°C to 0.9°C during inflammation and temperature decreases between −0.2°C to −0.5°C during ischemia.ConclusionsThe computational thermal models can explain previously published thermographic findings related to DTIs and pressure ulcers. It is concluded that infrared thermography can be used as an objective, non-invasive and quantitative means of early DTI diagnosis.Virtual slidesThe virtual slides for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1461254346108378.

Intraoperative Risk Factors Associated With Postoperative Pressure Ulcers in Critically Ill Patients

The risk for pressure ulcers is rarely identified in the perioperative period, and the influence of this period on risk factors has not been as rigorously studied as the postoperative period. We hypothesized that intraoperative risk factors exist, which increase the likelihood of a postoperative new-onset pressure ulcer. A retrospective observational study. A large midwestern U.S. quaternary care institution. A total of 2,695 adult surgical patients underwent operative procedures and received care in one of three ICUs using an electronic documentation application. None. The primary outcome was hospital-acquired pressure ulcer categorized as stages II, III, and IV; deep tissue injury; or unstageable. Univariate analyses comparing patients with and without the outcome of pressure ulcers were conducted for each preoperative characteristic or comorbidity. Patients were matched using the logit of the propensity score based solely on their preoperative comorbidities. Adjusted associations between development of pressure ulcers and intraoperative characteristics were determined in the postmatch cohort. We identified seven independent preoperative patients' characteristics and comorbidities in our adult surgical patient sample: American Society of Anesthesiologists risk classification 4 or 5, underweight body mass index, noncardiac surgery, history of congestive heart failure, renal disease, existing airway present prior to arrival in the operating room, and age. The only significant association in the matched dataset accounting for patient preoperative variability is the use of intraoperative blood products. Postoperative pressure ulcers developed in 10.7% of critically ill patients in our study. Only intraoperative use of blood products, not operative case length, hypotension, or vasopressor use, was associated with postoperative pressure ulcer development on adjusted analysis.

Comparison between a Computational Seated Human Model and Experimental Verification Data

Sitting-acquired deep tissue injuries (SADTI) are the most serious type of pressure ulcers. In order to investigate the aetiology of SADTI a new approach is under development: a musculo-skeletal model which can predict forces between the chair and the human body at different seated postures. This study focuses on comparing results from a model developed in the AnyBody Modeling System, with data collected from an experimental setup. A chair with force-measuring equipment was developed, an experiment was conducted with three subjects, and the experimental results were compared with the predictions of the computational model. The results show that the model predicted the reaction forces for different chair postures well. The correlation coefficients of how well the experiment and model correlate for the seat angle, backrest angle and footrest height was 0.93, 0.96, and 0.95. The study show a good agreement between experimental data and model prediction of forces between a human body and a chair. The model can in the future be used in designing wheelchairs or automotive seats.

Comparison between a computational seated human model and experimental verification data

Sitting-acquired deep tissue injuries (SADTI) are the most serious type of pressure ulcers. In order to investigate the aetiology of SADTI a new approach is under development: a musculo-skeletal model which can predict forces between the chair and the human body at different seated postures. This study focuses on comparing results from a model developed in the AnyBody Modeling System, with data collected from an experimental setup. A chair with force-measuring equipment was developed, an experiment was conducted with three subjects, and the experimental results were compared with the predictions of the computational model. The results show that the model predicted the reaction forces for different chair postures well. The correlation coefficients of how well the experiment and model correlate for the seat angle, backrest angle and footrest height was 0.93, 0.96, and 0.95. The study show a good agreement between experimental data and model prediction of forces between a human body and a chair. The model can in the future be used in designing wheelchairs or automotive seats.

Pressure Ulcer Prevention in the Intensive Care Unit

Pressure ulcers are a growing problem in health care, particularly in the intensive care unit where patients are often unstable and skin care can be overshadowed by airway, breathing, and circulation. In an effort to acknowledge this growing problem, a pressure ulcer protocol based on the subscales of the Braden Scale was developed for the intensive care population. The tool highlights specific interventions for each of its 6 subscales and provides criteria for the application of a preventive sacral dressing. A case study of a suspected deep tissue injury that resulted in a stage III pressure ulcer is used as an example of how this new tool can be applied to assist in the prevention of pressure ulcers.

Deep Tissue Injury in Development of Pressure Ulcers: A Decrease of Inflammasome Activation and Changes in Human Skin Morphology in Response to Aging and Mechanical Load

Molecular mechanisms leading to pressure ulcer development are scarce in spite of high mortality of patients. Development of pressure ulcers that is initially observed as deep tissue injury is multifactorial. We postulate that biomechanical forces and inflammasome activation, together with ischemia and aging, may play a role in pressure ulcer development. To test this we used a newly-developed bio-mechanical model in which ischemic young and aged human skin was subjected to a constant physiological compressive stress (load) of 300 kPa (determined by pressure plate analyses of a person in a reclining position) for 0.5–4 hours. Collagen orientation was assessed using polarized light, whereas inflammasome proteins were quantified by immunoblotting. Loaded skin showed marked changes in morphology and NLRP3 inflammasome protein expression. Sub-epidermal separations and altered orientation of collagen fibers were observed in aged skin at earlier time points. Aged skin showed significant decreases in the levels of NLRP3 inflammasome proteins. Loading did not alter NLRP3 inflammasome proteins expression in aged skin, whereas it significantly increased their levels in young skin. We conclude that aging contributes to rapid morphological changes and decrease in inflammasome proteins in response to tissue damage, suggesting that a decline in the innate inflammatory response in elderly skin could contribute to pressure ulcer pathogenesis. Observed morphological changes suggest that tissue damage upon loading may not be entirely preventable. Furthermore, newly developed model described here may be very useful in understanding the mechanisms of deep tissue injury that may lead towards development of pressure ulcers.

A NEW CUSTOM-CONTOURED CUSHION SYSTEM BASED ON FINITE ELEMENT MODELING PREDICTION

High internal stress in the deep tissues adjacent to bony prominences can cause deep tissue injuries. Therefore, internal stress in the soft tissue should be considered when the performance of anti-decubitus cushions is evaluated during cushion design. This paper reports on a custom-contoured cushion (CCC) system incorporated with a three-dimensional (3D) slice subject-specific finite element (FE) model to investigate the internal stress distribution in the soft tissues. This stress distribution was used to transform the interface pressure into the carving depth of the fabricated cushions based on the biomechanical characteristics of the cushion materials. The internal stress in the soft tissues was investigated using an FE model of buttocks and cushion made from three cushion materials. The cushion design was optimized according to the properties of the material. The simulated interface stress between the buttocks and the cushion (18 kPa) was consistent with the measured interface pressure of the CCC (17.1 kPa). The 3D FE model predicted the internal stress and displacement of the soft tissues and cushion. Additionally, it efficiently optimized the selection of cushion material. Fifty subjects (25 subjects with spinal cord injuries (SCI) and 25 healthy subjects) were recruited to investigate the interface pressure and perform subjective comfort evaluation. The CCC decreased the interface pressure under the buttocks and simultaneously increased the subjective comfort and stability. The effectiveness of the cushion materials was predicted by the CCC system, which also validated the clinical performance of decreasing interface pressure.

Elastin sequences trigger transient proinflammatory responses by human dermal fibroblasts

Following penetrating injury of the skin, a highly orchestrated and overlapping sequence of events helps to facilitate wound resolution. Inflammation is a hallmark that is initiated early, but the reciprocal relationship between cells and matrix molecules that triggers and maintains inflammation is poorly appreciated. Elastin is enriched in the deep dermis of skin. We propose that deep tissue injury encompasses elastin damage, yielding solubilized elastin that triggers inflammation. As dermal fibroblasts dominate the deep dermis, this means that a direct interaction between elastin sequences and fibroblasts would reveal a proinflammatory signature. Tropoelastin was used as a surrogate for elastin sequences. Tropoelastin triggered fibroblast expression of the metalloelastase MMP-12, which is normally expressed by macrophages. MMP-12 expression increased 1056 ± 286-fold by 6 h and persisted for 24 h. Chemokine expression was more transient, as chemokine C-X-C motif ligand 8 (CXCL8), CXCL1, and CXCL5 transcripts increased 11.8 ± 2.6-, 10.2 ± 0.4-, and 8593 ± 996-fold, respectively, by 6-12 h and then decreased. Through the use of specific inhibitors and protein truncation, we found that transduction of the tropoelastin signal was mediated by the fibroblast elastin binding protein (EBP). In silico modeling using a predictive computational fibroblast model confirmed the up-regulation, and simulations revealed PKA as a key part of the signaling circuit. We tested this prediction with 1 μM PKA inhibitor H-89 and found that 2 h of exposure correspondingly reduced expression of MMP-12 (63.9±12.3%) and all chemokine markers, consistent with the levels seen with EBP inhibition, and validated PKA as a novel node and druggable target to ameliorate the proinflammatory state. A separate trigger that utilized C-terminal RKRK of tropoelastin reduced marker expression to 65.0-76.5% and suggests the parallel involvement of integrin αVβ3. We propose that the solubilization of elastin as a result of dermal damage leads to rapid chemokine up-regulation by fibroblasts that is quenched when exposed elastin is removed by MMP-12.

Establishment of a novel rat model for deep tissue injury deterioration

Deep tissue injuries (DTIs) can become significant problems because of their rapid deterioration into deep pressure ulcers. Presently, no animal model of DTI deterioration has been developed. By concentrating pressure and shear stress in deep tissues while minimising pressure and shear stress in the overlying skin, we produced an effective rat model of DTI deterioration. Two-dimensional finite element method (FEM) simulated the distribution of pressure and shear stress under several pressure-loading conditions. FEM showed that concentrated shear stress in deep tissue with minimum shear stress in the overlying skin could be created by using a prominence and a cushion, respectively. On the basis of the results of FEM analysis, we selected suitable conditions for testing the rat DTI deterioration model. The compressed area was macroscopically observed until day 13, and histopathologic analysis via haematoxylin and eosin (H&E) staining was performed on days 3, 7 and 13. H&E staining showed that the distribution of tissue damage was similar to the predicted FEM results. Deep ulceration and tissue damage extending from deep tissues to the overlying skin and surrounding tissues were observed in the DTI deterioration model, which are similar to the clinical manifestations of DTI deterioration. In conclusion, a representative DTI deterioration model was established by concentrating high shear stress in deep tissues while minimising shear stress in the overlying skin. This model will allow a better understanding of the mechanisms behind DTI deterioration and the development of preventative strategies.

Deep Tissue Injury

Deep Tissue Injury

Oxidative stress and DNA damage signalling in skeletal muscle in pressure-induced deep tissue injury

The molecular mechanisms that contribute to the pathogenesis of pressure-induced deep tissue injury are largely unknown. This study tested the hypothesis that oxidative stress and DNA damage signalling mechanism in skeletal muscle are involved in deep tissue injury. Adult Sprague Dawley rats were subject to an experimental protocol to induce deep tissue injury. Two compression cycles with a static pressure of 100mmHg was applied to an area of 1.5cm(2) over the mid-tibialis region of right limb of the rats. The left uncompressed limb served as intra-animal control. Muscle tissues underneath compression region were collected for examination. Our analyses indicated that pathohistological characteristics including rounding contour of myofibres and extensive nuclei accumulation were apparently shown in compressed muscles. The elevation of 8OHdG immunopositively stained nuclei indicated the presence of oxidative DNA damage. Increase in oxidative stress was revealed by showing significant elevation of 4HNE and decreases in mRNA abundance of SOD1, catalase and GPx, and protein content of SOD2 in compressed muscles relative to control muscles. Increase in nitrosative stress was demonstrated by significant elevation of nitrotyrosine and NOS2 mRNA content. The activation of tumor suppressor p53 signalling was indicated by the remarkable increases in protein contents of total p53 and serine-15 phosphorylated p53. The transcript expression of the DNA-repairing enzyme, Rad23A, was significantly suppressed in compressed muscles. Our time-course study indicated that increased oxidative/nitrosative stress and proapoptotic signalling were maintained in muscles receiving increasing amount of compression cycles and post-compression time. Furthermore, resveratrol was found to attenuate the histological damage, oxidative/nitrosative stress and proapoptotic signalling in response to prolonged moderate compression. In conclusion, our findings are consistent with the hypothesis that oxidative stress and DNA damage signalling in skeletal muscle are involved in the underlying mechanisms responsible for the pathogenesis of pressure-induced deep tissue injury.

The histopathological investigation of the effect on regional and systemic tissues of the application of Medicinal Plant Extract Ankaferd Blood Stopper in deep tissue injuries in Rats

This study was planned to evaluate both the histopathological changes under light microscope as well as the systemic organ effects following application of Ankaferd Blood Stopper® (ABS) (a mixture of five plant extracts) in an animal model of deep tissue hemorrhage. A total of 50 Wistar Albino rats were divided into five groups of 10 rats each. The rats underwent femoral vein puncture and were treated with ABS tampon, ABS spray, or Surgicel, and one group was left untreated. After two weeks, each group underwent partial tissue excision from the same femoral region as well as from the brain, heart, kidney, and liver. The specimens from all groups were obtained from the femoral region after two weeks and evaluated under light microscope. The light microscope revealed no histopathological changes in neurovascular structures or in deep connective tissues in any of the groups. ABS provided hemostasis and was observed to stop bleeding. There were no histopathological changes at the tissue level and no pathological effects in other organs tissues under light microscope, and the remote organ tissue remained clear.

Clinical Nurses' Knowledge and Visual Differentiation Ability in Pressure Ulcer Classification System and Incontinence-associated Dermatitis

This study was done to compare clinical nurses' knowledge and visual differentiation diagnostic ability for the pressure ulcer classification system (PUCS) and incontinence-associated dermatitis (IAD). A convenience sample of 602 nurses took the pressure ulcer classification system and incontinence-associated dermatitis knowledge test (PUCS & IAD KT) and completed the visual differentiation tool (VDT), consisting of 21 photographs with clinical information. The overall mean score for correct answers was 14.5 (±3.2) in PUCS & IAD KT and 11.15 (±4.9) in PUCS & IAD VDT. Incorrect responses were most common for statements related to stage III, IAD for PUCS & IAD KT, and suspected deep tissue injury (SDTI), unstageable, and stage III for PUCS & IAD VDT. Significant correlations were found between PUCS & IAD KT and VDT (r=.48, p<.001). Factors affecting scores for PUCS & IAD VDT were PUCS & IAD KT, frequency of pressure ulcer, IAD management and participation in wound care education programs. Results indicate that nurses have an overall understanding of PUCS & IAD, but low visual differentiation ability regarding stage III, SDTI, and unstageable ulcers. Continuing education is needed to further improve knowledge and visual differentiation ability for PUCS & IAD.

The Nightingale Prize for best MBEC paper in 2011

The Nightingale Prize is named after Alfred Nightingale who was the first Editor in Chief of Medical and Biological Engineering and Computing, MBEC. He died in 1963 at the age of 40 [17]. He was a promising scientist and pioneer in the field of electromyography [14]. The prize was established in cooperation between the Institute of Physics and Engineering in Medicine and the International Federation of Medical and Biological Engineering. Since biomedical engineering papers do not collect citations so fast to allow citation frequency to be used as a selection criterion [12, 18] and the Nightingale prize is intended to recognize a recent paper an alternative procedure was established. The manuscripts that received a priority of 90 % or higher from the reviewers were selected with the exclusion of reviews and original papers with a rather senior author. The final list consisted out of 10 papers that will be recognized by this editorial. The selected winning paper of this year is by Sigal Portnoy, Nicolas Vuillerme, Yohan Payan and Amit Gefen from the department of Biomedical Engineering, Tel Aviv University, Israel. The paper is entitled ‘‘Clinically oriented real-time monitoring of the individual’s risk for deep tissue injury’’ [13]. This is one of the rare submissions where both reviewers not only gave a high score but recommended accept after first reading. The study aimed to formulate a patient-specific biomechanical model that can help in the continuously monitoring of internal tissue stresses in real time based on surface pressure data obtained form paraplegic patients in a wheelchair. The feasibility was tested on real patient data. It is the combination of state of the art numerical modeling and clinical verification that makes this manuscript to a nice example of quality biomedical engineering publication. The reviewers acknowledged that the paper reports on important work in the translation of engineering to clinical science in pressure ulcer prevention. Several papers related to the cardiovascular system were on the short list. Cardiac resynchronization therapy is important in preventing failure of the heart and for this the position of the coronary sinus, CS, lead is important. Corsi et al. [1] developed a method for quantifying CS lead position in the 3D domain throughout the cardiac cycle at implant and at follow-up using chest fluoroscopy. Transesophageal left ventricular electrogram-recording and temporary pacing was developed to improve patient selection for cardiac resynchronization by Heinke et al. [6]. The cardiorespiratory synchrogram is a stroboscopic-based graphical tool for evaluating phase-locking between cardiac and respiratory oscillators. This method was improved by including an adaptive delay in the cardiac oscillator by Kabir et al. [9]. Sola et al. [16] presented first experimental evidence that electrical impedance tomography is capable of measuring pressure pulses directly within the descending aorta and thereby opens the way to an unsupervised method for arterial blood pressure measurement. Westerhof et al. [19] reconstructed aortic pressure from 24-h intra-brachial and simultaneously obtained non-invasive finger pressure in hypertensive and normotensive patients. From these registrations, it was concluded that cardiac oxygen supply is compromised during the night in hypertensive patients. J. A. E. Spaan (&) Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands e-mail: j.a.spaan@amc.uva.nl 1 http://www.ipem.org.uk/ipem_public. 2 http://ifmbe.org/.

Combination of thermographic and ultrasonographic assessments for early detection of deep tissue injury

Early detection and intervention of deep tissue injury are important to lead good outcome. Although the efficiency of ultrasonographic assessment of deep tissue injury has been reported previously, it requires a certain level of skill for accurate assessment. In this study, we present an investigation of the combination of thermographic and ultrasonographic assessments for early detection of deep tissue injury. We retrospectively reviewed 28 early-stage pressure ulcers (21 patients) presenting at the University of Tokyo Hospital between April 2009 and February 2010, surveying the associated thermographic and ultrasonographic findings. The wound temperature patterns were divided into low, even and high compared with the surrounding skin. Ultrasonographic findings were classified into unclear layer structure, hypoechoic lesion, discontinuous fascia and heterogeneous hypoechoic area. All 13 ulcers that were associated with low temperature showed good outcome; three ulcers had even temperatures and 12 ulcers showed high temperature on thermographic assessment. The two deep tissue injuries were rated high on thermographic assessment and showed heterogeneous hypoechoic area findings on ultrasonographic assessment. No non-deep tissue injury lesion was associated with these two findings simultaneously. The combination of thermographic and ultrasonographic assessments is expected to increase the accuracy of the early detection of deep tissue injuries.

Prevention of deep tissue injury through muscle contractions induced by intermittent electrical stimulation after spinal cord injury in pigs

Deep tissue injury (DTI) is a severe medical complication that commonly affects those with spinal cord injury. It is caused by prolonged external loading of the muscles, entrapping them between a bony prominence and the support surface. The entrapment causes excessive mechanical deformation and increases in interstitial pressure, leading to muscle breakdown deep around the bony prominences. We proposed the use of intermittent electrical stimulation (IES) as a novel prophylactic method for the prevention of DTI. In this study, we assessed the long-term effectiveness of this technique in pigs that had received a partial spinal cord injury that paralyzed one hindlimb. The pigs recovered for 2 wk postsurgery, and subsequently, their paralyzed limbs were loaded to 25% of their body weights 4 h/day for 4 consecutive days each week for 1 mo. One group of pigs (n = 3) received IES during the loading, whereas another group (n = 3) did not. DTI was quantified using magnetic resonance imaging (MRI) and postmortem histology. In the group that did not receive IES, MRI assessments revealed signs of tissue damage in 48% of the volume of the loaded muscle. In the group that did receive IES, only 8% of the loaded muscle volume showed signs of tissue damage. Similar findings were found through postmortem histology. This study demonstrates, for the first time, that IES may be an effective technique for preventing the formation of DTI in loaded muscles after spinal cord injury.

HEAT TRANSFER MODEL AND QUANTITATIVE ANALYSIS OF DEEP TISSUE INJURY.

Deep tissue injuries (DTI) are serious lesions which may develop in deep tissue layers as a result of sustained tissue loading or ischemic injury. These lesions may not become visible on the skin surface until the injury reaches an advanced stage making their early detection a challenging task. Early diagnosis leading to early treatment mitigates the progression of lesion and remains one of the priorities in management. The aim of this study is to examine skin surface temperature distributions of damaged tissue and develop criteria for the detection of incipient DTI. A multilayer quantitative heat transfer model of the skin tissue was developed using finite element based software COMSOL Multiphysics. Thermal response of the skin surface was computed during deep tissue inflammation and deep tissue ischemia and then compared with that of healthy tissue. In the presence of a DTI, an increase of about 0.5°C in skin surface temperatures was noticed during initial phase of deep tissue inflammation, which was followed by a surface temperature decrease of about 0.2°C corresponding to persistent deep tissue ischemia. These temperature differences are large enough to be detected by thermographic imaging. This study, therefore, also enhances the understanding of the previously detected thermographic quantitative changes associated with DTI.

Improving Accuracy of Pressure Ulcer Staging and Documentation Using A Computerized Clinical Decision Support System

The purpose of this study was to evaluate an algorithm designed to assess and document pressure ulcers (PUs) via a computerized clinical decision support (CCDS) system. This study was conducted at Ochsner Medical Center, a 500-bed regional referral hospital. Thirty-one nurses, including RNs, LPNs, and student nurses, volunteered to participate in the study. The purpose of this descriptive study was to evaluate CCDS, a new tool for PU documentation, in a computer classroom setting. The CCDS program was built as an algorithm based on National Pressure Ulcer Advisory Panel's definitions. The CCDS incorporates descriptions in drop-down menus with required selections in depth, color, and characteristics of the PU by the nurse. The computer program then assigns a PU stage. Each participant used the decision support program to document the characteristics of 5 PUs presented in photographs and determine the stage. Data were analyzed to determine the accuracy of nurses' staging compared to that of the researcher and to test for differences between PU groups (overall accuracy, accuracy in accepting CCDS suggestion, and accuracy when override function used). The results indicate that nurses overall accurately staged PUs 64% of the time when using the CCDS program. However, nurses were significantly more accurate in staging suspected deep tissue injury and stage I PUs when they accepted the CCDS staging versus overriding the suggested stage (P < .01). Bivariate analysis did not identify any association between nurses' characteristics and accuracy in PU staging for suspected deep tissue injury, unstageable ulcers, and stages I and III (P > .05). Study findings suggest that the use of the CCDS may improve nurses' ability to stage PUs accurately. The correct staging of a PU is imperative in nursing's documentation and subsequent choice of best practices for improved outcomes.