Home

  • Home
    • » e-Newsletters

Staging Pressure Ulcers

Long-Term Care Nursing Advisor, March 26, 2004

The staging of pressure ulcers depicts tissue damage related to pressure. The same basic staging criteria have been in place for more than 10 years, but many nurses do not consistently follow proper staging. Part of the problem is that information about pressure ulcers is covered only superficially, if at all, in today's standard nursing education programs. As such, student nurses are not being trained to conduct thorough assessments of a condition affecting millions of people across the country. To compound the problem, many healthcare settings have limited support and education for new nurses to develop this skill after graduation. These circumstances lead to incomplete and often inaccurate assessments-and ultimately pose a risk-management dilemma.  

Pressure ulcers are staged using a universal system from the Wound, Ostomy and Continence Nurse (WOCN) Society in 1992 and the National Pressure Ulcer Advisory Panel in 1999. Each stage reflects the type and depth of observed damage. Staging is intended to show tissue destruction, not healing. The following describes the four stages of pressure ulcers: 

Stage I:    An observable, pressure-related alteration of intact skin, whose indicators, as compared with the adjacent or opposite area on the body, may include changes in one or more of the following: 

  • Skin temperature (e.g., coolness or warmth)
  • Tissue consistency (e.g., firm or boggy)
  • Sensation (e.g., pain or itching)

The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin the ulcer may appear with red, blue, or purple hues.

Stage II:   A partial-thickness skin loss involving the epidermis, dermis, or both.  The ulcer presents clinically as an abrasion, a blister, or a shallow crater.

Stage III:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to but not through underlying fascia. The ulcer presents clinically as a deep crater, with or without undermining of adjacent tissue.

Stage IV:   Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures such as tendon or joint capsule.

Remember, the staging classification system is only meant to depict tissue damage related to pressure. It should not be used to classify all wounds. 

 

Most Popular