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Pressure Ulcer Staging Guide

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Pressure Ulcer Staging Guide Pressure Ulcer Staging Guide Pressure Ulcer Staging Guide STAGE I STAGE IV Intact skin with non-blanchable Full thickness tissue loss with exposed redness of a localized area usually Reddened area bone, tendon, or muscle. Slough or eschar may be present on some parts Epidermis over a bony prominence. Darkly Epidermis pigmented skin may not have of the wound bed. Often includes undermining and tunneling. The depth visible blanching; its color may Dermis of a stage IV pressure ulcer varies by Dermis differ from the surrounding area. anatomical location. The bridge of the This area may be painful, firm, soft, nose, ear, occiput, and malleolus do not warmer, or cooler as compared to have subcutaneous tissue and these adjacent tissue. Stage I may be Adipose tissue ulcers can be shallow. Stage IV ulcers Adipose tissue difficult to detect in individuals with can extend into muscle and/or Muscle dark skin tones. May indicate "at supporting structures (e.g., fascia, Muscle risk" persons (a heralding sign of Bone tendon, or joint capsule) making risk). osteomyelitis possible. Exposed bone/ Bone tendon is visible or directly palpable. STAGE II DEEP TISSUE INJURY Partial thickness loss of dermis Blister Purple or maroon localized area of Reddened area presenting as a shallow open ulcer discolored intact skin or blood-filled Epidermis with a red pink wound bed, without Epidermis blister due to damage of underlying soft slough. May also present as an tissue from pressure and/or shear. The intact or open/ruptured serum-filled Dermis area may be preceded by tissue that is Dermis blister. Presents as a shiny or dry painful, firm, mushy, boggy, warmer, or shallow ulcer without slough or cooler as compared to adjacent tissue. bruising (bruising indicates Deep tissue injury may be difficult to suspected deep tissue injury). This Adipose tissue detect in individuals with dark skin Adipose tissue stage should not be used to tones. Evolution may include a thin describe skin tears, tape burns, Muscle blister over a dark wound bed. The Muscle wound may further evolve and become perineal dermatitis, maceration, or Bone Bone excoriation. covered by thin eschar. Evolution may be rapid exposing additional layers of STAGE III tissue even with optimal treatment. Full thickness tissue loss. Eshcar and/or slough Subcutaneous fat may be visible but UNSTAGEABLE Epidermis bone, tendon, or muscle are not Full thickness tissue loss in which the Epidermis exposed. Slough may be present base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/ but does not obscure the depth of Dermis tissue loss. May include Dermis or eschar (tan, brown or black) in the undermining and tunneling. The wound bed. Until enough slough and/or depth of a stage III pressure ulcer eschar is removed to expose the base of the wound, the true depth, and varies by anatomical location. The therefore stage, cannot be determined. Adipose tissue bridge of the nose, ear, occiput, and Adipose tissue Stable (dry, adherent, intact without malleolus do not have subcutaneous Muscle erythema or fluctuance) eschar on the tissue and stage III ulcers can be Muscle heels serves as "the body's natural Bone shallow. In contrast, areas of Bone (biological) cover" and should not be significant adiposity can develop removed. extremely deep stage III pressure NPUAP images, Copyright 2008. All rights reserved. ulcers. Bone/tendon is not visible or This material was prepared by CFMC, the Medicare Quality Improvement Organization for Colorado, under contract directly palpable. with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. PM– 2200-127 CO 2008 .
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