RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

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Assessment & Management of Stage I to IV Pressure UlcersAppendix H: Staging of WoundsStages of Pressure Ulcers(NPUAP, 2007)Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filledblister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded bytissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissueinjury may be difficult to detect in individuals with dark skin tones.Stage I: Intact skin with non-blanchable redness of a localizedarea usually over a bony prominence. Darkly pigmented skinmay not have visible blanching; its color may differ from thesurrounding area.Stage IStage II: Partial thickness loss of dermis presenting as a shallowopen ulcer with a red pink wound bed, without slough. May alsopresent as an intact or open/ruptured serum-filled blister.Stage IIStage III: Full thickness tissue loss. Subcutaneous fat may bevisible but bone, tendon or muscle are not exposed. Slough maybe present but does not obscure the depth of tissue loss. Mayinclude undermining and tunneling.Stage IIIStage IV: Full thickness tissue loss with exposed bone, tendon ormuscle. Slough or eschar may be present on some parts of thewound bed. Often includes undermining and tunneling.Stage IVUnstageable: 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.It is recommended that reverse staging of pressure ulcers NOT be used to describe the healing process of awound as this does not accurately reflect what is physiologically occurring in the ulcer (NPUAP, 2000). Pleasealso refer to definition of Reverse Staging of Pressure Ulcers. Descriptive characteristics or a validated toolfor measuring pressure ulcer healing, such as the PUSH tool, can be used to describe healing (NPUAP, 2000;Thomas et al., 1997).Pictures courtesy of KCI Medical Canada, Inc.88
Nursing Best Practice GuidelineAppendix I: Wound MeasurementIllustrated by N. Bauer. Published with permission.Surface Area = Length x WidthWhere length is the longest axis of the wound andwidth is 90 degrees to the length at the next longest axis.89
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