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Justin Finch, MD; Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC | April 18, 2022 | Contributor Information
Pressure injuries (also known as bedsores, decubitus ulcers, or pressure ulcers) are "localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device," as defined by the National Pressure Ulcer Advisory Panel (NPUAP).[1] The NPUAP replaced the term pressure ulcer with pressure injury in 2016, because the skin remains intact in the early stages of the injury. The NPUAP has also developed a staging system for classifying pressure injuries.[2] The above image demonstrates an advanced sacral pressure injury.
Note: Viewers of the slides should realize that it is sometimes difficult to appreciate color, wound depth, and other characteristics from a photograph. All classifications of slides in this presentation were made by wound-care professionals in person, not from photographs. In addition, despite attempts to increase the objectivity of pressure injury classification, research confirms that an element of subjectivity remains in wound assessment. Therefore, it is expected that viewers of the photographs may have differences of opinion about the characteristics and classification of some wounds.
Image from Wikimedia Commons | Nanoxyde. [CC by-SA 3.0 Unported.]
Justin Finch, MD; Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC | April 18, 2022 | Contributor Information
There are six categories (stages/grades) of pressure injuries, but only the numbered ones (ie, stages 1-4, shown) represent increasing degrees of skin/tissue damage. The other two categories are qualitative descriptors that do not necessarily reflect injury severity. As defined by the NPUAP, the six categories are as follows[1]:
Stage 1 - Nonblanchable erythema of intact skin
Stage 2 - Partial-thickness skin loss with exposed dermis
Stage 3 - Full-thickness skin loss
Stage 4 - Full-thickness skin and tissue loss
Unstageable pressure injury - Obscured, full-thickness skin and tissue loss
Deep-tissue pressure injury - Persistent, nonblanchable, deep red, maroon, or purple discoloration
The NPUAP also recognizes an etiologic category, medical device–related pressure injuries, which are staged as above, and mucosal membrane pressure injuries from use of a medical device, which cannot be staged because of the anatomy of the tissue.
Image courtesy of Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC.
Justin Finch, MD; Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC | April 18, 2022 | Contributor Information
Answer: Stage 1 - Nonblanchable erythema
At this stage the skin is intact, with nonblanchable redness (does not fade with pressure) in a localized area. The area pictured, like the vast majority of stage 1 wounds, is over a bony prominence.[1,2] Stage 1 wounds can be difficult to detect in persons with dark skin tones.[3] However, in these individuals the color of the affected skin may differ from that of the surrounding area. In comparison with adjacent tissue, the site may be painful, firm, soft, and/or warm or cool.[1] Patients with a stage 1 pressure injury are at risk for a more serious, higher-stage pressure injury.
Image courtesy of Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC.
Justin Finch, MD; Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC | April 18, 2022 | Contributor Information
Answer: Stage 2 - Partial-thickness skin loss with intact dermis
This pressure injury belongs in stage 2 because of the loss of the epidermis and the presence of intact dermis. Partial-thickness skin loss has the appearance of a shallow, open ulcer. Indications of intact dermis include a flat, red-pink wound bed without slough. This category of pressure injury can also present as an intact or open/ruptured blister or as a shiny or dry, shallow ulcer displaying neither slough nor bruising.[1]
Image courtesy of Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC.
Justin Finch, MD; Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC | April 18, 2022 | Contributor Information
Answer: Stage 3 - Full-thickness skin loss
This wound demonstrates full-thickness skin loss with necrosis of the epidermis and dermis. Although slough can be seen in the center of the wound bed, there is no evidence of muscle, tendon, or bone involvement. The depth of stage 3 pressure injuries differs according to anatomic location.[2] In areas with little to no subcutaneous tissue (eg, the bridge of the nose, ear, occiput, malleolus), the wound will be shallow. In areas of significant adiposity, stage 3 pressure injuries can be extremely deep.
Image courtesy of Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC.
Justin Finch, MD; Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC | April 18, 2022 | Contributor Information
Answer: Stage 4 - Full-thickness skin and tissue loss
This is a stage 4 pressure injury located on a patient's coccyx. Stage 4 wounds exhibit full-thickness skin and tissue loss with exposure of bone, tendon, or muscle. Depending on the anatomic location, the depth of stage 4 pressure injuries will vary.[2] Thus, stage 4 wounds may be shallow in areas with little to no subcutaneous tissue, or they can extend into muscle and/or supporting structures. Any involvement of bone increases the likelihood of the development of osteomyelitis or osteitis.[4]
Image courtesy of Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC.
A wound is assigned to this category when full-thickness tissue loss is present but the pressure injury's depth is totally concealed by slough (yellow, white, tan, gray, green, or brown) and/or eschar (tan, brown, or black). To appropriately stage these wounds, slough and/or eschar will need to be chemically or mechanically removed. Once these tissues have been cleared, the category can be determined.[2] However, do not remove stable eschar (necrotic tissue that is dry, intact, and adherent and has no erythema or fluctuance) on the heels, because this tissue serves as a natural cover.[1]
Image courtesy of Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC.
Injury to the deep, underlying soft tissue due to pressure and/or shear* produces intact, localized areas of purple or maroon skin or blood-filled blisters.[1,2] In comparison with adjacent tissue, the affected tissue may be painful, firm, boggy, and/or warm or cool.[5] Eventually, the wound will evolve, exposing the true depth of the injury.
*Shear is a mechanical force that is in the same plane as the skin. Shear occurs when friction holds the skin in place but the body is pulled by gravity, as when a patient slips down in bed from a semi-upright position.
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Contributor Information
Authors
Justin Finch, MD
Founding Partner
Central Connecticut Dermatology
Cromwell, CT;
Associate Professor
Department of Dermatology
University of Connecticut Health Center
Farmington, CT
Disclosure: Justin Finch, MD, is an investigator for: AbbVie, Brickell Biotech, Cara, Corrona, Dermavant, Dermira, Incyte, and Novartis.
Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC
Adjunct Clinical Instructor
University of Cincinnati
Cincinnati, OH
Disclosure: Lu Ann Reed, RN, MSN, CRRN, BC-RN, LNHA, WCC, DWC, has disclosed no relevant financial relationships.
Reviewers
Kyle E. Robinson, MD
Department of Plastic and Reconstructive Surgery
Atrium Health Wake Forest Baptist Hospital
Winston-Salem, NC
Disclosure: Kyle E. Robinson, MD, has disclosed no relevant financial relationships.
Joseph A. Molnar, M.D., Ph.D., F.A.C.S
Professor of Plastic and Reconstructive Surgery and Regenerative Medicine
Medical Director
Wound Care and Hyperbaric Center
Associate Director
Burn Center
Wake Forest University School of Medicine
Winston-Salem, NC
Disclosure: Joseph A. Molnar, M.D., Ph.D., F.A.C.S, discloses the following: Received grant/research funds from Clinical Cell Culture for co-investigator; received honoraria from Integra Life Sciences for speaking and teaching; received honoraria from Healogics for board membership; received honoraria from Anika Therapeutics for consulting; received honoraria from Food Matters for consulting.
Ryan E. Rebowe, MD
Department of Plastic and Reconstructive Surgery
Atrium Health Wake Forest Baptist Hospital
Winston-Salem, NC
Disclosure: Ryan E. Rebowe, MD, has disclosed no relevant financial relationships.
Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016 Nov/Dec;43(6):585-597. PMID: 27749790 [Full text].
Sullivan R. A 5-year retrospective study of descriptors associated with identification of stage I and suspected deep tissue pressure ulcers in persons with darkly pigmented skin. Wounds. 2014 Dec;26(12):351-9. PMID: 25785778
Wong D, Holtom P, Spellberg B. Osteomyelitis Complicating Sacral Pressure Ulcers: Whether or Not to Treat With Antibiotic Therapy. Clin Infect Dis. 2019 Jan 15; 68(2): 338–342. PMID: 29986022 [Full text]
Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. PMID: 21328752 [Full text]
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