The previous article in this series helped answered the question – What is a pressure ulcer? – as well as outlining how prevalent they are, how they develop and who is at risk of developing a pressure ulcer. In this article, we’ll be looking at answering another key question – What are the stages of a pressure ulcer? – and we’ll also look at the cost of prevention vs treatment of the various stages of pressure ulcers.
The EPUAP (European Pressure Ulcer Advisory Panel), NPUAP (National Pressure Ulcer Advisory Panel) and the PPPIA (Pan Pacific Pressure Injury Alliance) collaboratively released The International Pressure Classification System in 2009 and it was re-published in 2014 and it provides a good overview of the stages of pressure ulcers.
What are the stages of a pressure ulcer?
The are 4 category/ stage classifications of pressure ulcers:
- Category/Stage I: Nonblanchable Erythema
- Category/Stage II: Partial Thickness Skin Loss
- Category/Stage III: Full Thickness Skin Loss
- Category/Stage IV: Full Thickness Tissue Loss
We have outlined each of these stages in the slides below along with illustrations and example imagery. Please note, some of the imagery in the slides below may be considered graphic.
Stage I: Nonblanchable Erythema
May indicate “at risk” individuals.
Intact skin with non-blanchable redness of a localised 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 as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones.
Stage II: Partial Thickness Skin Loss
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. Presents as a shiny or dry shallow ulcer without slough or bruising.*
This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury
Stage III: Full Thickness Skin Loss
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 Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Stage IV: Full Thickness Tissue Loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunnelling.
The depth of a Category/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.
Category/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.
Unstageable: Depth Unknown
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 Category/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.
Suspected Deep Tissue Injury: Depth Unknown
Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Deep tissue injury may be difficult to detect in individuals with dark skin tones. 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.
If you have a pressure ulcer
If you think you may be developing or at risk of developing a pressure sore, the next article addresses the question – How can I tell if I have a pressure sore? – however, with pressure it is best to err on the side of caution and contact your local GP, healthcare professional or medical center.
This article is part 2 of a 5-part series on pressure care and pressure ulcers to help raise awareness of pressure ulcers as part of STOP Pressure Ulcers 2019.
Preventing and Treating Pressure Ulcers with the Star Lock Cushion
The Star Lock Cushion is one of the best pressure care cushions available for preventing and treating pressure ulcers of wheelchair users. It is clinically proven for the treatment Stage IV pressure ulcers.