Pressure Ulcer Stages

The National Pressure Ulcer Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. 

Pressure Ulcer Stages

• Stage I – A stage I pressure ulcer presents as 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 as compared to adjacent tissue.
• Stage II – A stage II pressure ulcer is characterized by partial thickness loss of the dermis, presenting as a shallow open ulcer with a red pink wound bed, without slough. Others may present as an intact or open/ruptured serum-filled blister. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
• Stage III – A stage III pressure ulcer involves 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. Stage III pressure ulcers may include undermining and tunneling.
• Stage IV – A stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. A stage IV pressure ulcer often involves undermining and tunneling.
• Unstageable – A pressure ulcer should be described as unstageable if the base is obscured by eschar or slough. Until enough slough and/or eschar is removed to expose the base of the wound, neither the true depth, nor the stage, can be determined.
• Deep Tissue Injury – Deep-Tissue Injury is defined 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. 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. Even with optimal treatment, evolution may be rapid, exposing additional layers of tissue.

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