Pressure Wound Staging

A quick summary of The National Pressure Ulcer Advisory Panel pressure sore staging guidelines.

• By Joseph Duffy
• Dec 01, 2010

Key in understanding what mattress solutions are right for which patient is understanding pressure wound staging. The National Pressure Ulcer Advisory Panel provides complete guidelines on staging pressure sores at www.npuap.org/pr2.htm. Here is a summary of the panel’s wound stages:

Suspected Deep Tissue Injury
This will have a purple or maroon localized area of discolored intact skin or blood-filled blister.

Stage 1
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Stage 2
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, but without slough.

Stage 3
Full thickness tissue loss with visible subcutaneous fat. Slough might be present and the wound might include undermining and tunneling.

Stage 4
Full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar might be present; and will often include undermining and tunneling.

Unstageable
Full thickness tissue loss in which the base of the ulcer is covered by or eschar in the wound bed.

Generally, the more severe a pressure wound, the more complex the mattress that will be required. A patient with a single stage 2 sore or less might simply need a gel overlay, while a patient with multiple stage 3 or 4 wounds might need a low-air loss, alternating pressure mattress.

This article originally appeared in the December 2010 issue of HME Business.