From the Guidelines
Pressure ulcers are staged using a four-stage classification system based on the depth of tissue damage, with additional categories for unstageable and deep tissue pressure injuries, as recommended by the American College of Physicians guideline 1.
Staging Classification
The staging classification system is as follows:
- Stage 1: intact skin with non-blanchable redness in a localized area, usually over a bony prominence
- Stage 2: partial-thickness skin loss with exposed dermis, appearing as a shallow open ulcer with a red-pink wound bed without slough
- Stage 3: full-thickness skin loss where subcutaneous fat may be visible but bone, tendon, and muscle are not exposed
- Stage 4: full-thickness skin and tissue loss with exposed bone, tendon, or muscle
Additional Categories
There are also two additional categories:
- Unstageable pressure injuries: full-thickness skin and tissue loss with the base covered by slough or eschar, preventing direct visualization of the wound bed
- Deep tissue pressure injuries: localized area of persistent non-blanchable deep red, maroon, or purple discoloration
Assessment and Documentation
When assessing pressure ulcers, it is essential to:
- Clean the wound thoroughly before staging
- Document the location, size, depth, presence of undermining or tunneling, wound bed appearance, exudate, and surrounding skin condition Accurate staging is crucial for developing appropriate treatment plans and monitoring healing progress, as emphasized in the American College of Physicians guideline 1.
From the Research
Staging Pressure Ulcers (PrU)
To stage pressure ulcers, it is essential to follow the updated staging system of the National Pressure Injury Advisory Panel 2, 3. The revised staging system uses Arabic numerals to denote stages and describes the extent of tissue loss present and the anatomical features that may or may not be present in the stage of injury.
Key Considerations
- Pressure injuries are localized damage to skin or soft tissue, commonly occurring over bony prominences 2.
- Comprehensive skin assessments are crucial for evaluating pressure injuries 2.
- The revised definition of a pressure injury describes the injuries as usually occurring over a bony prominence or under a medical or other device 3.
- Each definition now describes the extent of tissue loss present and the anatomical features that may or may not be present in the stage of injury 3.
Clinical Practice Guidelines
- The European Pressure Ulcer Advisory Panel, the Pan Pacific Pressure Injury Alliance, and the National Pressure Ulcer Advisory Panel have updated the 'Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline' (CPG) in 2019 4.
- The 2019 guideline update builds on the previous 2014 version to ensure consistency and comparability 4.
- A systematic review of clinical practice guidelines and other best practice recommendations for pressure injury risk assessment in the United States found that risk assessment was consistently positioned as a critical first step in the prevention of pressure injuries 5.