Pressure Ulcers
“A pressure ulcer is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of
pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated
with pressure ulcers; the significance of these factors is yet to be elucidated.”
– the National Pressure Ulcer Advisory Panel (NPUAP)
Stage I: At this stage, the skin is intact, with non-blanchable redness in a localized area, usually over a bony
prominence. Can be difficult to detect in individuals with dark skin tones. Darkly pigmented skin may not have
visible redness, but the color of the affected skin may differ from that of the surrounding area. The area may be
painful, soft, warmer, or cooler as compared with adjacent tissue. A Stage I pressure ulcer indicates that the
patient is at risk for a more serious pressure ulcer.
Stage II: Partial-thickness loss of the dermis presents as a shallow open ulcer with a red-pink wound bed, without
slough. A Stage II pressure ulcer may also present as an intact or open/ruptured serum-filled or serosanginous
filled blister, or as a shiny or dry shallow ulcer without slough or bruising.
*This stage should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration or
excoriation.
Stage III: 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. The wound may include undermining and/or
tunneling.
**The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of nose, ear, occiput and
malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant
adiposity can develop extremely deep Stage III pressure ulcers. Bone or tendon is not visible or directly palpable.
, Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present, as
may undermining and tunneling.
*The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of nose, ear, occiput and
malleolus do not have subcutaneous tissue and Stage IV ulcers can be shallow.
**Stage IV ulcers can extend into muscle and/or supporting structures (i.e. fascia, tendon or joint capsule) making
osteomyelitis possible. Exposed bone and/or tendon is visible or directly palpable.
Unstageable ulcer: Full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough
(yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough
and/or eschar are removed to expose the base of the wound, the true depth cannot be determined, but it will be
either a Stage III or IV.
*Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural
(biological) cover” and should not be removed.
Suspected Deep Tissue Injury: Purple or maroon localized areas of discolored intact skin or blood-filled blisters
are a result of damage to the underlying soft tissue from pressure and/or shear. The evolution may include a thin
blister over a dark wound bed. The wound may further evolve and become covered with thin eschar. The
progression of this type of injury can be rapid, exposing additional layers of tissue even with optimal treatment.
*The affected tissue may be painful, firm, mushy, boggy, warmer, or cooler compared with adjacent tissue.
“A pressure ulcer is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of
pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated
with pressure ulcers; the significance of these factors is yet to be elucidated.”
– the National Pressure Ulcer Advisory Panel (NPUAP)
Stage I: At this stage, the skin is intact, with non-blanchable redness in a localized area, usually over a bony
prominence. Can be difficult to detect in individuals with dark skin tones. Darkly pigmented skin may not have
visible redness, but the color of the affected skin may differ from that of the surrounding area. The area may be
painful, soft, warmer, or cooler as compared with adjacent tissue. A Stage I pressure ulcer indicates that the
patient is at risk for a more serious pressure ulcer.
Stage II: Partial-thickness loss of the dermis presents as a shallow open ulcer with a red-pink wound bed, without
slough. A Stage II pressure ulcer may also present as an intact or open/ruptured serum-filled or serosanginous
filled blister, or as a shiny or dry shallow ulcer without slough or bruising.
*This stage should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration or
excoriation.
Stage III: 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. The wound may include undermining and/or
tunneling.
**The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of nose, ear, occiput and
malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant
adiposity can develop extremely deep Stage III pressure ulcers. Bone or tendon is not visible or directly palpable.
, Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present, as
may undermining and tunneling.
*The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of nose, ear, occiput and
malleolus do not have subcutaneous tissue and Stage IV ulcers can be shallow.
**Stage IV ulcers can extend into muscle and/or supporting structures (i.e. fascia, tendon or joint capsule) making
osteomyelitis possible. Exposed bone and/or tendon is visible or directly palpable.
Unstageable ulcer: Full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough
(yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough
and/or eschar are removed to expose the base of the wound, the true depth cannot be determined, but it will be
either a Stage III or IV.
*Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural
(biological) cover” and should not be removed.
Suspected Deep Tissue Injury: Purple or maroon localized areas of discolored intact skin or blood-filled blisters
are a result of damage to the underlying soft tissue from pressure and/or shear. The evolution may include a thin
blister over a dark wound bed. The wound may further evolve and become covered with thin eschar. The
progression of this type of injury can be rapid, exposing additional layers of tissue even with optimal treatment.
*The affected tissue may be painful, firm, mushy, boggy, warmer, or cooler compared with adjacent tissue.
