Pressure ulcer prevention

Learn more about pressure ulcer categories

Recently revised International definitions and classification system for pressure ulcers have been released by NPUAP and EPUAP (National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009)¹.

Category/ Stage 1 Persistent, non blanchable erythema.

Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. A stage I may indicate a patient at risk.

Category/ Stage 2 Partial thickness skin loss.

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. This should not be used when describing skin tears for example – be aware that if bruising is present it may indicate deep tissue injury.

Category/ Stage 3 Full thickness skin loss.

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Be aware that the depth here varies by location for example on an ear where subcutaneous tissue is not present.

Category/ Stage 4 Subcutaneous tissue loss.

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Be aware that the depth here varies by location for example on an ear where subcutaneous tissue is not present; stage IV wounds can extend into muscle and supporting structures.

 

In the USA NPUAP have added two further categories which may be referred to as stage 4
in other classification systems such as the one issued by EPUAP.

Suspected deep tissue injury

Purple or maroon localised area of discoloured intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Unstagable

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Pressure Ulcers are often difficult to diagnose, there has been confusion particularly between Pressure Ulcers and a wound caused by moisture. It is critical to correctly diagnose as both prevention and treatment programmes may differ.²¹

Key characteristics to be aware of (adapted from EPUAP statement)²¹

References

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