Stages of a pressure ulcer

The National Pressure Ulcer Advisory the panel classifies pressure ulcers into 6 main stages:1

Suspected deep tissue injury
*Artist's interpretation

Deep tissue injury has been recognized by the NPUAP,2 the Wound Ostomy Continence Society,3 and the Centers for Medicare and Medicaid Services (CMS)4 as an important concern. NPUAP identifies deep tissue injury as a purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.1

The area may be painful, firm, mushy, boggy, warmer, or cooler compared to adjacent tissue before the typical signs of deep tissue injury appear (i.e., localized discoloration or blood-filled blister). Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Deep tissue injury may be difficult to detect in individuals with dark skin tones.1
Suspected deep tissue injury
Deep tissue injury on right lateral foot at fifth metatarsal head. Note intact skin, profound purple area.		 Suspected deep tissue injury  Suspected deep tissue injury
Similar presentation noted to heel and left buttock, right ischial tuberosity.		 Suspected deep tissue injury  Suspected deep tissue injury
Deep tissue injury observed on darkly pigmented skin.

Progression of deep tissue injury
Suspected deep tissue injury
Deep tissue injury over sacrum upon admission. Note intact skin and profound dark area.		 Suspected deep tissue injury  Suspected deep tissue injury
Same deep tissue injury area as noted at left, approximately 1 week later. Note progression to an ulcer with eschar.		 Suspected deep tissue injury
Same deep tissue injury as noted previously, during debridement;
after debridement the ulcer is an unavoidable Stage IV.

Determining degree of deep tissue damage beneath blister roof

To determine the depth of tissue damage beneath the blister roof, press gently on the tissue beneath the blister roof with a fingertip and then release. It is likely there is tissue congestion and probably necrosis if the tissue feels soft and spongy. If the tissue rebounds easily when pressure is removed, there may be mild congestion.5
Suspected deep tissue injury Heel blister with bloody/brown fluid beneath blister roof. Suspected deep tissue injury Same heel approximately 2 weeks later, after fluid has been absorbed and eschar has developed, confirming necrosis.

Stage I
*Artist's interpretation

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

Darkly pigmented skin may not have visible blanching; its color 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.
  Stage I pressure ulcer     Stage I pressure ulcer Stage I pressure ulcer     Stage I pressure ulcer
    A system should be in place to identify the Stage I pressure ulcer in individuals with darker skin tones.

 

Stage II
*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.
  Stage II pressure ulcers     Stage II pressure ulcers     Stage II pressure ulcers     Stage II pressure ulcers     Stage II pressure ulcers
 

* Bruising indicates suspected deep tissue injury.

 

Stage III
*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 tunneling.

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 adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
  Stage III pressure ulcers     Stage III pressure ulcers     Stage III pressure ulcers

 

Stage IV
*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 tunneling.

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.
  Stage IV pressure ulcers     Stage IV pressure ulcers     Stage IV pressure ulcers     Stage IV pressure ulcers

 

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. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body’s natural (biologic) cover and should not be removed.

Unstageable pressure ulcers     Unstageable pressure ulcers     Unstageable pressure ulcers     Unstageable pressure ulcers     Unstageable pressure ulcers
 
 

References [+]

  1. National Pressure Ulcer Advisory Panel. NPUAP Staging Report. Available at: http://www.npuap.org/. Accessed October 10, 2006.
  2. Black JM. Moving toward consensus on deep tissue injury and pressure ulcer staging. Adv Skin Wound Care. 2005 Oct;18(8):415-421.
  3. Wound Ostomy and Continence Nurses Society. WOCN Society Response to NPUAP White Papers: Deep Tissue Injury, Stage I Pressure Ulcers, and Stage II Pressure Ulcers. 9th National NPUAP Conference, February 25-26, 2005.
  4. CMS Online Manual System Pub 100-07: State Operations Provider Certification. Transmittal 4 (Appendix PP). Centers for Medicare and Medicaid Services Web site. Available at: http://www.cms.hhs.gov/Transmittals. Accessed December 5, 2006.
  5. Sussman C. Assessment of the skin and wound. In: Sussman C, Bates-Jensen BM, eds. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. Gaithersburg, Md: Aspen Publishers Inc; 1998:49-82.

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