II. Precautions
- Accurate grading requires Debridement of necrosis first
- Use other grading schemes for staging of Diabetic Foot Ulcers and Venous Stasis Ulcers
- Macerated skin (moisture induced wounds) are not staged
III. Staging: NPUAP Guidelines for Pressure Ulcers (pink skin, not purple)
- Stage 1
- Nonblanchable erythema of intact skin
- Stage 2
- Stage 3
- Full thickness skin loss with subcutaneous damage
- Ulcer extends down to underlying fascia
- Presents as deep crater
- Stage 4
- Full thickness skin loss with extensive destruction
- Tissue necrosis
- Damage to Muscle, bone, tendon or joint capsule
- Additional stages in which depth is unknown
- Depth Unknown - Unstageable
- Full-thickness wound with base obscured by extensive slough or eschar
- Depth Unknown - Suspected Deep
- Intact skin with localized purple or maroon discoloration (or bulla with blood)
- Deep tissue injury suspected beneath overlying lesion
- Depth Unknown - Unstageable
- Images
