Pressure Ulcer (PU) Staging, Prevention, and Other Wound/Skin Types

What is Pressure Ulcer Injury? A localized damage to the skin and underlying soft tissue due to an intense and/or prolonged pressure or pressure in combination with shear, usually over a bony prominence or related to a device. The injury can present as intact skin or an open ulcer and may be painful.

Stages/Categories / Description / Stages/Categories / Description
Stage I – Non-blanchable redness
/ Intact skin with a localized area of non-blanchable erythema (redness) / Stage II – Partial-Thickness
Skin loss w/ exposed dermis. / Wound bed is viable, pink or red, moist. May be an intact or ruptured serum-filled blister. Can be mistaken for Moisture Associated skin damage.
Stage III – Full-Thickness
Tissue loss extends through the dermis to subcutaneous (adipose, fat) tissue. / Small amount of slough (yellow fibrinous tissue) and/or eschar(dry dark scab) may be visible. The depth of tissue damage varies by location. Undermining & tunneling may occur. / Stage IV – Full-Thickness
Skin & tissue loss extend to fascia, muscle, tendon, ligament, cartilage or bone. / Small amount of slough and/or eschar may be visible. Undermining and/or tunneling often occur. Depth varies by anatomical location.
Unstageable
Obscured full-thickness skin & tissue loss /
Skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. / Deep Tissue Injury
Persistent non-blanchable deep red, maroon or purple discoloration
/ Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.
Other wounds/Injuries that may be mistaken for Pressure Ulcer.
Medical Device Related Injury
This injury due to hand splint / The injuries result from the use of devices designed and applied for medical reasons. The resultant pressure injury generally conforms to the pattern or shape of the device. / Incontinence Associated Dermatitis
/ An irritation of the skin leading to erosion; caused by prolonged exposure to urine, stool, or both
Arterial Ulcer
/ A wound caused by impaired blood flow of artery to the lower leg and foot, results in restriction in blood supply to tissue and tissue death. / Diabetic Ulcer
/ A wound on the foot of a person w/ diabetes, with heavy calloused area around the wound
Venous ulcer
/ An open skin lesion of the leg or foot that occurs in an area affected by high blood pressure inside the vein. / PU Prevention: 1) Positioning in bed (every 2 hours, head of
bed</=30˚, avoid position to the affected side)
2) Wheelchair (shift weight frequently, use cushion)
3) Use special mattress
4) Skin care
5) Nutrition (enough protein & fluid)
6) Self-care (check body head to toe)

Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. (2014). National Pressure Ulcer Advisory Panel. Retrieved from

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