Stage I pressure injury: non-blanchable erythema Stage II pressure injury: partial thickness skin loss Stage III pressure injury: full thickness skin loss
• Intactskinwithnon-blanchablerednessofalocalisedareausuallyoverabonyprominence.
• Darklypigmentedskinmaynothavevisibleblanching;itscolourmaydifferfromthesurroundingarea.
• Theareamaybepainful,firm,soft,warmerorcoolercomparedtoadjacenttissue.
• Maybedifficulttodetect in individualswithdarkskintones.
• Mayindicate“atrisk”persons(aheraldingsignofrisk).
• Partialthicknesslossofdermispresentingasashallow,open wound with a red-pink wound bed, withoutslough.
• Mayalsopresentasanintactoropen/rupturedserum-filledblister.
• Presentsasashinyordry,shallowulcerwithoutsloughorbruising(NBbruisingindicatessuspecteddeeptissueinjury).
• StageIIPIshouldnotbeusedtodescribeskintears,tapeburns,perinealdermatitis,macerationorexcoriation.
• Full thickness tissue loss. Subcutaneous fat may bevisiblebutbone, tendonormusclearenotexposed.Sloughmaybepresentbutdoesnotobscurethedepthoftissueloss.Mayincludeunderminingandtunnelling.
• ThedepthofastageIIIPIvariesbyanatomicallocation.Thebridgeofthenose,ear,occiputandmalleolusdonothavesubcutaneoustissueandstageIIIPIscanbeshallow. Incontrast,areasofsignificantadipositycandevelopextremelydeepstageIIIPIs.Boneortendonisnotvisibleordirectlypalpable.
Stage IV pressure injury: full thickness tissue loss Unstageable pressure injury: depth unknown Suspected deep tissue injury: depth unknown
• Full thickness tissue loss with exposed bone, tendonormuscle.Sloughorescharmaybepresentonsomepartsofthewoundbed.
• The depth of a stage IV pressure injury varies byanatomical location. The bridge of the nose, ear,occiput and malleolus do not have subcutaneoustissueandthesePIscanbeshallow.Stage IVPIscanextend intomuscleand/or supportingstructures (e.g.fascia, tendonor joint capsule)makingosteomyelitispossible.Exposedboneortendon isvisibleordirectlypalpable.
• Full thickness tissue loss inwhich thebaseof thePI iscoveredbyslough(yellow,tan,grey,greenorbrown)and/oreschar(tan,brownorblack)inthePIbed.
• Untilenoughslough/escharisremovedtoexposethebaseofthePI,thetruedepth,andthereforethestage,cannotbedetermined. Stable (dry, adherent, intactwithouterythemaorfluctuance)escharon theheelsserves as the body’s natural biological cover andshouldnotberemoved.
• Purpleormaroonlocalisedareaordiscoloured,intactskinorblood-filledblisterduetodamageofunderlyingsofttissuefrompressureand/orshear.Theareamaybeprecededbytissuethatispainful,firm,mushy,boggy,warmerorcoolerascomparedtoadjacenttissue.
• Deeptissueinjurymaybedifficulttodetectinindividualswithdarkskintone.
• Evolutionmayincludeathinblisteroveradarkwoundbed.ThePImayfurtherinvolveandbecomecoveredby thin eschar. Evolution may be rapid, exposingadditionallayersoftissueevenwithoptimaltreatment.
Table 7.1 NPUAP/EPUAP pressure injury classification system4
All3DgraphicsdesignedbyJarradGittos,GearInteractive,http://www.gearinteractive.com.auPhotosstage,I,IV,unstageableandsuspecteddeeptissueinjurycourtesyC.Young,LauncestonGeneralHospital.PhotosstageIIandIIIcourtesyK.Carville,SilverChain.Usedwithpermission.
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HOW TO CLASSIFY AND DOCUMENT PRESSURE INJURIESThe NPUAP/EPUAP Pressure injury classification system provides a consistent and accurate means by which the severity of a pressure injury can be communicated and documented.
