NATIONAL PRESSURE INJURY ADVISORY PANEL PRESSURE ULCER/INJURY STAGING
What is a Pressure Ulcer/Injury?
Stage 1 Pressure Ulcer/Injury:
Non-blanchable erythema of intact skin
Light skin Dark skin
Stage 2 Pressure Ulcer/Injury:
Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin 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.
This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Light skin Dark skin
Stage 3 Pressure Ulcer/Injury:
Full-thickness skin loss
Light skin Dark skin
Stage 4 Pressure Ulcer/Injury:
Full-thickness skin and tissue loss
Light skin Dark skin
Unstageable Pressure Ulcer/Injury:
Obscured full-thickness skin and tissue loss
Deep Tissue Pressure Ulcer/Injury
Persistent non-blanchable deep red, maroon, or purple discoloration
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. Discoloration may appear differently in darkly pigmented skin. 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, or other underlying structures are visible, this indicates a full thickness pressure ulcer/injury (Unstageable, Stage 3, or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.
