Stages of Pressure Injury

Stage I Pressure Injury

• 
• 
• Non blanching when pressed. (Redness with pressure persists after 30 mins In dark pigmented skin the color may be red or blue)

• Epidermis, irregular or regular area of erythema, firm and boggy

Stage II Pressure Injury

• Partial thickness skin loss, through dermis.Early fibrosis & pigment changes occur

• May look like a blister, abrasion or shallow ulcer with more distinct edgesI

• 
• 

Stage III Pressure Injury

• Full thickness skin loss, extending through subcutaneous fat.Base of wound infected, often with some areas of slough foul smelling tissue.

• 
• Presents like a crater and may have undermining and tunneling of adjacent tissue.

• 

Stage IV Pressure Injury

• Undermining is even more common and there may be sinus tracts.

• Extension of injury through deep fascia, bone is visible at base of wound. Osteomyelitis & septic arthritis can be present.

• 
• 

Unstageable Pressure Injury

• Actual depth unknown as need to remove the eschar and /or slough.

• 
• 
• Present as a dry or wet eschar or/and slough.Palpate to estimate the depth.

Deep Tissue Pressure Injury

• 
• Bottom Up”. Deep purple or maroon “bruised” area, or as a blood blister under intact skin

• Recognize through visual or palpation

• 

Pressure Injury associated Medical devices

• 
• 
• 
• 

Choose Stage I Pressure Injury

• 
• 
• 
• 

What is the definition of pressure injury?

• is one of the major causes of skin breakdown in lying, sitting and occurs during transfers, reaching, weight shifts or repositioning.

• Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device’ – National Pressure Ulcer Advisory Panel (NPUAP) (2016)

• Reduce the duration and magnitude of pressure over vulnerable areas of the body

• the force of rubbing two surfaces against one another.