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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Related Studies

Ontology: Pressure ulcer stage (C1718233)

Concepts Qualitative Concept (T080)
ICD9 707.2
SnomedCT 420592002
LNC MTHU020927
English Pressure ulcer stage (observable entity), Pressure ulcer stages, Pressure ulcer stage, chronic decubitus ulcer stage, Pressure ulcer stage (diagnosis)
Spanish estadio de úlcera por decúbito (entidad observable), estadio de úlcera por decúbito, estadio de escara

Ontology: stage I pressure ulcer (C2074666)

Concepts Disease or Syndrome (T047)
ICD9 707.21
English Pressure ulcer, stage I, stage I decubitus ulcer, stage I pressure ulcer, stage I pressure ulcer (diagnosis)

Ontology: stage II pressure ulcer (C2074667)

Concepts Disease or Syndrome (T047)
ICD9 707.22
English Pressure ulcer, stage II, stage II pressure ulcer, stage II decubitus ulcer, stage II pressure ulcer (diagnosis)

Ontology: stage III pressure ulcer (C2074668)

Concepts Disease or Syndrome (T047)
ICD9 707.23
English Pressure ulcer,stage III, Pressure ulcer, stage III, stage III pressure ulcer, stage III decubitus ulcer, stage III pressure ulcer (diagnosis)

Ontology: stage IV pressure ulcer (C2074669)

Concepts Disease or Syndrome (T047)
ICD9 707.24
English Pressure ulcer, stage IV, stage IV pressure ulcer, stage IV pressure ulcer (diagnosis), stage IV decubitus ulcer