PRESSURE ULCERS
Stage 1 Stage 2 Stage 3 Stage 4
STAGING
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
Stage I differ from the surrounding area.
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound
Stage II 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.
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle
Stage III are not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may
Stage IV be present on some parts of the wound bed. Often include undermining and tunneling.
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by
slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the
Unstageable 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.
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
DTI preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to
adjacent tissue.
Treatment
• Identify at risk patients and institute precautions and assessments.
• Keep skin dry, sheets wrinkle free, turn and reposition frequently.
• Assess and document status of ulcer.
• Treatment may include creams, dressings, debridement, grafting, vacuum assisted suction.
Image Credit: By Babagolzadeh (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
NRSNG.com - “Tools and Confidence to Succeed in Nursing School.”
©2017 TazKai LLC | NRSNG.com - Reproduction Strictly Prohibited
Disclaimer information at NRSNG.com
Stage 1 Stage 2 Stage 3 Stage 4
STAGING
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
Stage I differ from the surrounding area.
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound
Stage II 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.
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle
Stage III are not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may
Stage IV be present on some parts of the wound bed. Often include undermining and tunneling.
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by
slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the
Unstageable 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.
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
DTI preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to
adjacent tissue.
Treatment
• Identify at risk patients and institute precautions and assessments.
• Keep skin dry, sheets wrinkle free, turn and reposition frequently.
• Assess and document status of ulcer.
• Treatment may include creams, dressings, debridement, grafting, vacuum assisted suction.
Image Credit: By Babagolzadeh (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
NRSNG.com - “Tools and Confidence to Succeed in Nursing School.”
©2017 TazKai LLC | NRSNG.com - Reproduction Strictly Prohibited
Disclaimer information at NRSNG.com
