Pressure Sore Stages Revised

In February 2007, the National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer (bedsore, pressure sore, decubitus ulcer), and the stages of pressure ulcers. Two new stages, suspected deep tissue injury and unstageable, were added.

While the definitions include some specific medical terminology that may be difficult to understand, it makes sense family members of a resident to familiarize themselves with the jargon used by nurses and physicians. The new definitions are provided below. Further explanation of the definitions will follow in future posts.

Pressure Ulcer Definition 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 and/or friction.

Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Stage I:
Intact skin with redness on a localized area of the body usually over a bony prominence.

Stage II:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

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. May include undermining and tunneling.

Stage IV:
Stage 4 bedsores have full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Unstageable:
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.

Website Resources:

Pressure Ulcer Stages Revised by NPUAP, National Pressure Ulcer Advisory Panel, February 2007.