Pressure Ulcer Staging Guide

In the fast-paced and demanding world of healthcare, nursing students must equip themselves with a solid foundation of knowledge and skills. Among these essential skills is the ability to accurately stage pressure ulcers.

Pressure ulcers, also known as bedsores or pressure sores, are localized injuries to the skin and underlying tissue caused by prolonged pressure, friction, or shearing forces. Proper and careful skin assessment, including pressure ulcer staging, are essential for effective management and treatment.

As future health care professionals, nursing students must prioritize their clients’ well-being by developing and maintaining a strong foundation in pressure ulcer staging.

By consistently practicing this skill, students can improve their assessment accuracy, enhance client outcomes, and contribute to a culture of quality care. Remember, pressure ulcers are a challenge to treat and a preventable condition.

Pressure Ulcer Staging

Pressure ulcer staging is fundamental to nursing care, enabling health care professionals to assess, document, and manage pressure ulcers effectively. By understanding the key characteristics and classification systems, nursing students can contribute to providing optimal care, implementing appropriate interventions, and preventing the progression of pressure ulcers.

Early detection, prevention, and a multidisciplinary approach are vital in managing pressure ulcers and improving client outcomes.

How Pressure Ulcers Happen

Also known as decubitus ulcers, pressure ulcers are injuries to the skin and its underlying tissues, usually in bony prominences. Pressure ulcers can develop when a prolonged pressure is applied to a specific area.

The extra pressure disrupts the blood flow. Without blood supply, the affected skin becomes starved of oxygen and nutrients, and begins to break down, leading to an ulcer forming.

Other examples of low oxygen issues happening inside the body are:

• Myocardial infarction (the heart is not getting enough oxygen)
• Deep vein thrombosis (a blockage that causes insufficient blood flow)
• Peripheral vascular disease (narrowing of blood vessels, disrupting oxygen perfusion)

Stages of Pressure Ulcers

What are the different stages of pressure ulcer, and how does one identify each stage?

Stage 1 Pressure Ulcer: Non-Blanchable Ulcer

What is non-blanching? When you push the skin, the normal reaction would be that the area turns white and then returns to its original skin color. This is similar to a capillary refill wherein you check clients for peripheral oxygenation. Blanchable is when there is a red ulcer that you’ve pushed, and the redness goes away and then comes back.

On the other hand, non-blanchable is when you push your client’s skin, and the area stays red, meaning there is little or no blood flow going to that area.

Pressure ulcers are mostly seen on bony prominences like the hip, tailbone, and heels.

Stage 2 Pressure Ulcer: Partial Thickness

Partial thickness skin loss means that the wound is confined to the skin layers. Damage does not extend below the dermis. However, once the skin is open, there is a risk potential for infection.

Stage 3 Pressure Ulcer: The Subcutaneous Layer

In basic anatomy, the integumentary system primarily comprises the epidermis, dermis, subcutaneous tissue, and all the way to the muscles and bones. At this stage, the subcutaneous tissues are now visible. This is most prominent around the sacral area or the coccyx.

On admission, nurses carefully assess the skin of a client and take pictures of any abnormalities or wounds. This assessment and documentation is key to effective client care. This assessment is important for better client outcomes. The nurse can consult wound care for treatment if needed and also prevent further skin breakdown.

Stage 4 Pressure Ulcer: Full-Thickness Tissue Loss

In this stage, the ulcer has gone deeper, reaching the muscles and bones. The muscles and bones are now visible; thus, this condition is termed tissue necrosis. As this happens, muscles and bones are affected together with the neighboring structures. Stage four pressure ulcers appear as deep pockets, and the client is at increased risk of acquiring a wound-related infection.

Stage 5 Pressure Ulcer: Eschar

Considered unstageable, this type of pressure ulcer is charcoal-like, typically tan, brown, or black, and may be crusty. Eschar is dead tissue (necrotic) that sheds or falls off from the skin. It is commonly seen with pressure ulcer wounds.

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