Module 1 NDNQI Pressure Injuries
Stage 3 Pressure Injury - ✔️✔️Full thickness loss of skin,
adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound
edges) are often present.
Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical
location; areas of significant adiposity can develop deep wounds.
Undermining and tunneling may occur.
Fascia, muscle, tendon, ligament, cartilage or bone is not exposed.
Pressure - ✔️✔️Pressure is the force (per unit area) exerted perpendicular to the skin
surface. Pressure damages the skin and underlying tissues by
(1) directly deforming and damaging tissue;
(2) compressing small blood vessels hindering blood flow and nutrient supply and
(3) through ischemia-reperfusion injury. When pressure is redistributed over a greater
surface area, the pressure is less intense in any one area.
Shear stress - ✔️✔️Shear stress is the force (per unit area) exerted parallel to the
tissue.
Shear strain - ✔️✔️Shear strain is the actual distortion or deformation of tissue as a
result of shear stress. Some shear strain occurs at rest. Shear strain is intensified in
certain clinical situations (e.g., raising the head of the bed > 30 degrees; dragging rather
than lifting while repositioning). One layer of tissue slides over another deforming
adipose and muscle tissue and disrupting blood flow.
Stage 1 Pressure Injury - ✔️✔️Intact skin with a localized area of non-blanchable
erythema, which may appear differently in darkly pigmented skin. Presence of
blanchable erythema or changes in sensation, temperature, or firmness may precede
visual changes. Color changes do not include purple or maroon discoloration; these
may indicate deep tissue pressure injury.
Slough - ✔️✔️Whitish dead tissue
Eschar - ✔️✔️Dead tissue like a scab that sheds or falls off from healthy skin. It's
caused by burns and pressure wounds
Eschar is typically tan, brown, or black, and may be crusty
Blanch Test - ✔️✔️Blanch Test: Apply light pressure. Skin should blanch or lighten.
Release. Skin should return to normal color due to normal reactive hyperemia.
Blanchable: Skin blanches with pressure. Color returns immediately with release.
, Non-blanchable: No blanch, persistent redness in lightly pigmented skin.
Stage 2 Pressure Injury - ✔️✔️Partial thickness skin loss with exposed dermis.
The wound bed is viable, pink or red, moist, and may also present as an intact or
ruptured serum-filled blister.
Adipose (fat) is not visible and deeper tissues are not visible.
Granulation tissue, slough and eschar are not present.
These injuries commonly result from adverse microclimate and shear in the skin over
the pelvis and shear in the heel.
Pressure Injury Categories/Stages - ✔️✔️The National Pressure Ulcer Advisory Panel
(NPUAP) 2016 revised classification system for pressure injuries includes1 four
numerical stages for situations where the deepest anatomic structures of the injury can
be identified.
Accuracy in pressure injury categorization/staging is important for prompt and
appropriate care.
Stage 4 Pressure Injury - ✔️✔️Full thickness skin and tissue loss with exposed or
directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer
Slough and/or eschar may be visible.
Epibole (rolled edges), undermining and/or tunneling often occur.
Unstageable Pressure Injury - ✔️✔️When the extent of tissue damage is obscured by
slough or eschar. Stage 3 or 4 pressure injury beneath.
*Mucosal Membrane Pressure Injuries should not be staged
Deep Tissue Pressure Injury (DTPI) - ✔️✔️Intact or non-intact skin with localized area
of persistent non-blanchable deep red, maroon, purple discoloration or epidermal
separation revealing a dark wound bed or blood filled blister. Pain and temperature
change often precede skin color changes.
This injury results from intense and/or prolonged pressure and shear forces at the bone-
muscle interface.
The wound may evolve rapidly to reveal the actual extent of tissue injury, or may
resolve without tissue loss.
If necrotic tissue/subcutaneous tissue/granulation tissue/fascia/muscle/other underlying
structures visible, indicates a full thickness pressure injury (Unstageable, Stage 3 or
Stage 4).
DTPI Mechanisms of Tissue Damage - ✔️✔️Deep muscle tissue is more susceptible to
the effects of pressure and shear than skin.
Stage 3 Pressure Injury - ✔️✔️Full thickness loss of skin,
adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound
edges) are often present.
Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical
location; areas of significant adiposity can develop deep wounds.
Undermining and tunneling may occur.
Fascia, muscle, tendon, ligament, cartilage or bone is not exposed.
Pressure - ✔️✔️Pressure is the force (per unit area) exerted perpendicular to the skin
surface. Pressure damages the skin and underlying tissues by
(1) directly deforming and damaging tissue;
(2) compressing small blood vessels hindering blood flow and nutrient supply and
(3) through ischemia-reperfusion injury. When pressure is redistributed over a greater
surface area, the pressure is less intense in any one area.
Shear stress - ✔️✔️Shear stress is the force (per unit area) exerted parallel to the
tissue.
Shear strain - ✔️✔️Shear strain is the actual distortion or deformation of tissue as a
result of shear stress. Some shear strain occurs at rest. Shear strain is intensified in
certain clinical situations (e.g., raising the head of the bed > 30 degrees; dragging rather
than lifting while repositioning). One layer of tissue slides over another deforming
adipose and muscle tissue and disrupting blood flow.
Stage 1 Pressure Injury - ✔️✔️Intact skin with a localized area of non-blanchable
erythema, which may appear differently in darkly pigmented skin. Presence of
blanchable erythema or changes in sensation, temperature, or firmness may precede
visual changes. Color changes do not include purple or maroon discoloration; these
may indicate deep tissue pressure injury.
Slough - ✔️✔️Whitish dead tissue
Eschar - ✔️✔️Dead tissue like a scab that sheds or falls off from healthy skin. It's
caused by burns and pressure wounds
Eschar is typically tan, brown, or black, and may be crusty
Blanch Test - ✔️✔️Blanch Test: Apply light pressure. Skin should blanch or lighten.
Release. Skin should return to normal color due to normal reactive hyperemia.
Blanchable: Skin blanches with pressure. Color returns immediately with release.
, Non-blanchable: No blanch, persistent redness in lightly pigmented skin.
Stage 2 Pressure Injury - ✔️✔️Partial thickness skin loss with exposed dermis.
The wound bed is viable, pink or red, moist, and may also present as an intact or
ruptured serum-filled blister.
Adipose (fat) is not visible and deeper tissues are not visible.
Granulation tissue, slough and eschar are not present.
These injuries commonly result from adverse microclimate and shear in the skin over
the pelvis and shear in the heel.
Pressure Injury Categories/Stages - ✔️✔️The National Pressure Ulcer Advisory Panel
(NPUAP) 2016 revised classification system for pressure injuries includes1 four
numerical stages for situations where the deepest anatomic structures of the injury can
be identified.
Accuracy in pressure injury categorization/staging is important for prompt and
appropriate care.
Stage 4 Pressure Injury - ✔️✔️Full thickness skin and tissue loss with exposed or
directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer
Slough and/or eschar may be visible.
Epibole (rolled edges), undermining and/or tunneling often occur.
Unstageable Pressure Injury - ✔️✔️When the extent of tissue damage is obscured by
slough or eschar. Stage 3 or 4 pressure injury beneath.
*Mucosal Membrane Pressure Injuries should not be staged
Deep Tissue Pressure Injury (DTPI) - ✔️✔️Intact or non-intact skin with localized area
of persistent non-blanchable deep red, maroon, purple discoloration or epidermal
separation revealing a dark wound bed or blood filled blister. Pain and temperature
change often precede skin color changes.
This injury results from intense and/or prolonged pressure and shear forces at the bone-
muscle interface.
The wound may evolve rapidly to reveal the actual extent of tissue injury, or may
resolve without tissue loss.
If necrotic tissue/subcutaneous tissue/granulation tissue/fascia/muscle/other underlying
structures visible, indicates a full thickness pressure injury (Unstageable, Stage 3 or
Stage 4).
DTPI Mechanisms of Tissue Damage - ✔️✔️Deep muscle tissue is more susceptible to
the effects of pressure and shear than skin.
