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Pressure Ulcer Stage
Aka: Pressure Ulcer Stage, Decubitus Ulcer Stage, Stage 1 Pressure Ulcer, Stage 2 Pressure Ulcer, Stage 3 Pressure Ulcer, Stage 4 Pressure Ulcer, Decubitus Ulcer Grade, Pressure Ulcer Grade, Pressure Sore Grade
- 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
- Staging: NPUAP Guidelines for Pressure Ulcers (pink skin, not purple)
- Stage 1
- Nonblanchable erythema of intact skin
- Stage 2
- Superficial or partial thickness skin loss
- No slough or eschar
- Ulcer involves Epidermis or Dermis
- Skin Abrasion
- Blister
- Distinguish from other type of skin breakdown (Skin Tears, maceration or erosion)
- 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
- Resources
- NPUAP Illustrations
- http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/