Staging Pressure Ulcers
The following information was copied verbatim from the AHCPR
Guidelines, which is consistent with the recommendations of the
National Pressure Ulcer Advisory Panel (NPUAP) Consensus
Nonblanchable erythema of intact skin, the heralding lesion of
skin ulceration. In individuals with darker skin, discoloration
of the skin, warmth, edema, induration, or hardness may also be
A Stage I pressure ulcer is an observable pressure related alteration
of intact skin whose indicators as compared to the adjacent or opposite
area on the body may include changes in one or more of the following:
skin temperature (warmth or coolness), tissue consistency (firm or boggy
feel) and/or sensation (pain, itching).
The ulcer appears as a defined area of persistent redness in lightly
pigmented skin, whereas in darker skin tones, the ulcer may appear with
persistent red, blue, or purple hues.
Partial thickness skin loss involving epidermis, dermis, or
both. The ulcer is superficial and presents clinically as an
abrasion, blister, or shallow crater.
Full thickness skin loss involving damage to or necrosis of
subcutaneous tissue that may extend down to, but not through,
underlying fascia. The ulcer presents clinically as a deep crater
with or without undermining of adjacent tissue.
Full thickness skin loss with extensive destruction, tissue
necrosis, or damage to muscle, bone, or supporting structures
(e.g., tendon, joint capsule). Undermining and sinus tracts also
may be associated with Stage 4 pressure ulcers.
Clinical studies indicate that as deep ulcers heal, the lost
muscle, fat and dermis is NOT replaced. Instead, granulation
tissue fills the defect before re-epithelialization. Given this
information, it is not appropriate to reverse stage a healing
ulcer. For example, a pressure ulcer stage 3 does not become a
stage 2 or a stage 1 in your documentation during healing. You
must chart the progress by noting an improvement in the
characteristics (size, depth, amount of necrotic tissue, amount
of exudate, etc.). [Taken from the NPUAP Report Vol.4, No.2,
The above information on staging was condensed and reprinted
from the AHCPR Publication No. 92-0050, Pressure Ulcers in
Adults: Prediction and Prevention. For copies of this booklet,
call 202-512-1800 or 800-358-9295.