II. Precautions

  1. Accurate grading requires Debridement of necrosis first
  2. Use other grading schemes for staging of Diabetic Foot Ulcers and Venous Stasis Ulcers
  3. Macerated skin (moisture induced wounds) are not staged

III. Staging: NPUAP Guidelines for Pressure Ulcers (pink skin, not purple)

  1. Stage 1
    1. Nonblanchable erythema of intact skin
  2. Stage 2
    1. Superficial or partial thickness skin loss
    2. No slough or eschar
    3. Ulcer involves Epidermis or Dermis
      1. Skin Abrasion
      2. Blister
    4. Distinguish from other type of skin breakdown (Skin Tears, maceration or erosion)
  3. Stage 3
    1. Full thickness skin loss with subcutaneous damage
    2. Ulcer extends down to underlying fascia
    3. Presents as deep crater
  4. Stage 4
    1. Full thickness skin loss with extensive destruction
    2. Tissue necrosis
    3. Damage to Muscle, bone, tendon or joint capsule
  5. Additional stages in which depth is unknown
    1. Depth Unknown - Unstageable
      1. Full-thickness wound with base obscured by extensive slough or eschar
    2. Depth Unknown - Suspected Deep
      1. Intact skin with localized purple or maroon discoloration (or bulla with blood)
      2. Deep tissue injury suspected beneath overlying lesion

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