Stages of pressure ulcer

The National Pressure Ulcer Advisory Panel classify pressure ulcers into 4 main stages: 1

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*Artist's interpretation

Intact skin with non blanchable redness of a localised area usually over a bony prominence.

Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. A Stage I may be difficult to detect in individuals with dark skin tones. The development of a Stage I may indicate that the patient is at risk.

 

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A system should be in place to identify the Stage I pressure ulcer in individuals with darker skin tones.
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*Artist's interpretation

Partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister.

A Stage II ulcer presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tapeburns, perineal dermatitis, maceration, or excoriation.

 

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* Bruising indicates suspected deep tissue injury.

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*Artist's interpretation

Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling.

The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant fatty tissue can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

 

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*Artist's interpretation

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunnelling.

The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

 

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Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.

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