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Stages of Pressure Ulcers: For Hospital Staff

Evaluating pressure ulcers/injuries includes describing and documenting them and tracking their progress. Staging systems provide you with a guide in this process. The information in this sheet is an overview of the staging and treatment of pressure ulcer/injury. Follow your healthcare provider’s recommendations per National Pressure Ulcer Advisory Panel (NPUAP).

Remember to: Assess, Describe, and Document

Deep tissue injury

Persistent non-blanchable deep red, maroon or purple discoloration

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented or darker skin tones (changes in skin color or redness may not be easily recognized and differ from surrounding skin areas). This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer/injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions (NPUAP, 2016)

Goal: Determine the extent of the injury, support blood flow, and reduce risk of further breakdown of skin.

  • Redistribute pressure.

  • Prevent shear, friction, and moisture build-up.

  • Assess the patient per organization guidelines.

  • Notify healthcare provider if wound is painful.

  • Look for signs of infection: redness, pain, drainage, increase warmth, odor, fever

  • Discuss pressure ulcer/injury with the healthcare provider.

  • Apply dressing to reduce risk of further damage

Stage 1

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury (NPUAP, 2016). Note: It may be difficult to determine blanching in darker skin tones. The affected area may differ in color from the surrounding skin.

Goal: Reduce risk of further progression of the ulcer/injury and support blood flow.

  • Redistribute pressure.

  • Prevent shear, friction, and moisture build-up.

  • Follow up with the healthcare provider per instructions.

  • Notify healthcare provider if wound is painful.

  • Look for signs of infection: redness, pain, drainage, increase warmth, odor, fever

  • Discuss pressure injury with the healthcare provider.

  • Apply a protective dressing to reduce risk of further damage, if indicated.

  • Cleanse and lightly moisturize the skin. Note: Never massage the affected area. This can cause further damage to tissue.

Stage 2

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) (NPUAP, 2016).

Goal: Maintain a clean, moist wound bed to prevent infection and promote healing. Reduce risk of further progression of the ulcer/injury and support blood flow, prevent full-thickness injury and continue to promote healing.

  • Redistribute pressure.

  • Prevent shear, friction, and moisture build-up.

  • Follow up with the healthcare provider per instructions.

  • Notify healthcare provider if wound is painful.

  • Look for signs of infection: redness, pain, drainage, increase warmth, odor, fever

  • Discuss pressure ulcer/injury with the healthcare provider.

  • Apply dressing to reduce risk of further damage

  • Apply dressing to keep wound bed moist and promote healing.

  • Use skin prep to protect fragile skin from adhesives.

  • Reevaluate nutritional intake.

Stage 3

Full-thickness loss of skin, in which adipose tissue (fat) is visible in the ulcer/injury and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury (NPUAP, 2016).  

Goal: Maintain a clean, moist wound bed to prevent infection and promote new tissue growth.

  • Redistribute pressure.

  • Prevent shear, friction, and moisture build-up.

  • Follow up with healthcare provider, as instructed.

  • Notify healthcare provider if wound is painful.

  • Look for signs of infection: redness, pain, drainage, increase warmth, odor, fever

  • Discuss pressure ulcer/injury with the healthcare provider.

  • Apply dressing to reduce risk of further damage

  • Remove dead tissue (debridement), if needed by healthcare provider or certified wound specialist.

  • Absorb drainage.

  • Fill the ulcer cavity with appropriate dressing.

  • Evaluate the need for nutritional consultation.

Stage 4

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer/injury. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury (NPUAP, 2016).

Goal: Maintain a clean, moist wound bed to prevent infection, reduce drainage, remove dead tissue, and establish an environment for new tissue growth.

  • Redistribute pressure.

  • Prevent shear, friction, and moisture build-up.

  • Reassess the patient per facility’s guidelines.

  • Notify healthcare provider if wound is painful.

  • Look for signs of infection: redness, pain, drainage, increase warmth, odor, fever

  • Discuss pressure ulcer/injury with the healthcare provider.

  • Apply dressing to reduce risk of further damage.

  • Talk with the healthcare provider, as indicated.

  • Report bone involvement.

  • Treat infection with antibiotics, if indicated.

  • Discuss with healthcare provider whether surgery is needed.

Unstageable

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer/injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer/injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed(NPUAP, 2016).

Goal: Determine stage upon removal of slough or eschar, provide moist environment, and prevent further breakdown.

  • Remove dead tissue (debridement), if needed consult healthcare provider or certified wound specialist.

  • Do not debride the heel unless signs of infection are present. Follow-up with healthcare provider for wound debridement.

  • Reassess ulcer/injury stage once base is visible.

  • Notify healthcare provider if wound is painful.

  • Look for signs of infection: redness, pain, drainage, increased warmth, odor, fever

  • Discuss pressure ulcer/injury with healthcare provider.

To learn more

For more information, go to the Pressure Ulcer/Injury Resource mobile app.

Author: StayWell Custom Communications
Last Annual Review Date: 8/1/2018
Copyright © The StayWell Company, LLC. except where otherwise noted.
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