Pressure Ulcer Staging

Question 1

Stage I

Answer 1

Intact skin with non-blanch-able redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching, but instead as local coloration differing from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.

Question 2

Stage II

Answer 2

Partial-Thickness tissue loss of the of the dermis presenting as a shallow open ulcer with red or pink wound bed. May present as an intact or ruptured serum-filled blister or presents as a shiny or dry shallow ulcer without sloughing or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Question 3

Stage III

Answer 3

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 to depth of tissue loss. May include undermining and tunneling. Bone and tendon are not visible or directly palpable. The depth of a stage III pressure ulcer varies by anatomical location.

Question 4

Stage IV

Answer 4

Full-Thickness tissue loss with exposed bone, tendon or muscle that is visible or directly palpable. Slough or Escher may be present on some parts of the wound bed. Undermining and tunneling may be present. The depth of a stage IV pressure ulcer varies by anatomical location.

Question 5

Suspected Deep Tissue Injury

Answer 5

Purple or maroon localized areas of intact skin or blood-filled blister due to damage of the underlying soft tissue form pressure and/or shear forces. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. The evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by a thin Eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

Question 6

Unstageable

Answer 6

Full-Thickness tissue loss in which the base of the ulcer is covered 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 is removed to expose the base of the wound, the true depth.