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.