Stages of Pressure Sores
Pressure sores are classified into four distinct stages based on the depth of tissue damage, with each stage requiring specific management approaches.
Stage 1
- Non-blanchable erythema of intact skin
- Skin appears red and does not blanch when pressure is applied
- May also present with changes in temperature, firmness, or sensation compared to adjacent tissue
- Reversible in most cases if pressure is relieved promptly, though 8.7-22.1% may progress to higher stages if not properly managed 1
Stage 2
- Partial-thickness skin loss involving epidermis and/or dermis
- Presents as a shallow open ulcer with a red-pink wound bed
- May also appear as an intact or ruptured serum-filled blister
- No slough or bruising is present (bruising indicates suspected deep tissue injury)
Stage 3
- Full-thickness tissue loss extending into subcutaneous fat
- Bone, tendon, and muscle are not visible or directly palpable
- Slough may be present but does not obscure the depth of tissue loss
- May include undermining and tunneling into adjacent tissue 2
- Depth varies by anatomical location (areas with significant adipose tissue may develop very deep ulcers)
Stage 4
- Full-thickness tissue loss with exposed bone, tendon, or muscle
- Slough or eschar may be present on some parts of the wound
- Often includes undermining and tunneling
- High risk of developing osteomyelitis, with prevalence ranging from 17% to 58% in patients with stage IV pressure injuries 3
Additional Classifications
Unstageable
- Full-thickness tissue loss where the base of the ulcer is covered by slough or eschar
- True depth and stage cannot be determined until debridement
- Should not be debrided if stable, dry, intact without erythema or fluctuance
Deep Tissue Injury
- Purple or maroon localized area of discolored intact skin or blood-filled blister
- Results from damage to underlying soft tissue from pressure and/or shear
- May rapidly evolve to reveal the actual extent of tissue injury
Management Considerations
Prevention is the most effective approach, involving risk assessment, pressure redistribution, and regular repositioning 3, 4
Treatment strategies vary by stage:
- Stage 1: Pressure redistribution, moisturizers, protective dressings
- Stage 2: Moist wound healing, hydrocolloid or foam dressings 3
- Stage 3: Debridement of necrotic tissue, appropriate dressings based on exudate level
- Stage 4: Comprehensive wound care, evaluation for osteomyelitis, possible surgical intervention 3
Nutritional support with protein supplementation improves wound healing across all stages 3
Common Pitfalls
- Misclassifying darkly pigmented skin, where erythema may be difficult to detect
- Failing to differentiate between moisture-associated skin damage and pressure injuries
- Inadequate assessment of wound depth, particularly when slough or eschar is present
- Neglecting to evaluate for biofilm formation and infection, especially in stages 3 and 4 2
- Overuse of antibiotics without clear evidence of infection 2
Proper staging of pressure sores is essential for determining appropriate treatment strategies and monitoring healing progress. Regular reassessment is necessary as wounds may improve or deteriorate based on multiple factors including pressure relief, nutrition, and infection management.