- Stage I – Observable
pressure-related alteration of intact skin whose indicators,
as compared to the adjacent or opposite area of the body.
May include changes in one or more of the following:
- Skin temperature (warmth or
coolness)
- Tissue consistency (firm or boggy
feel) and/or
- Sensation (pain, itching)
The ulcer appears as a defined area of persistent
redness in lightly pigmented skin, whereas in darker
skin tones, the ulcer may appear with persistent red,
blue, or purple hues.
- Stage II – Partial thickness skin
loss involving:
1.
Epidermis
2.
Dermis, or both.
3.
The ulcer is superficial and presents clinically as an
abrasion, blister, or shallow
crater.
- Stage III – Full thickness skin loss
involving damage to, or necrosis of:
1.
Subcutaneous tissue that may extend down to, but not
through, underlying fascia.
The ulcer presents clinically as a
deep crater with or without undermining of adjacent
tissue.
- Stage IV – Full thickness skin loss
with:
1.
Extensive destruction,
2.
Tissue necrosis, of
3.
Damage to muscle, bone, or supporting structures (tendon,
joint capsule).
Undermining and sinus tracts also may
be associated with Stage IV pressure ulcers.