Definitions:
Pressure Ulcer: Any lesion caused by unrelieved pressure resulting in damage of underlying
tissue. Shear and friction may be contributing factors. Pressure ulcers are usually located over
bony prominences and are staged to classify the degree of tissue damage observed.
- Stage I: Non-blanchable erythema of intact skin, the heralding lesion of skin ulceration.
In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or
hardness may also be indicators.
- State II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is
superficial and presents as an abrasion, blister, or shallow crater.
- Stage III: Full thickness skin loss involving damage to or necrosis of 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 extensive destruction, tissue necrosis, or damage
to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and
sinus tracts (tunnels) may also be associated with Stage IV pressure ulcers.
- Non-observable: Wound is unable to be visualized due to an orthopedic device, dressing,
etc. A pressure ulcer cannot be accurately staged until the deepest viable tissue layer is
visible; this means that wounds covered with eschar and/or slough cannot be staged, and
should be documented as non-observable.
WOCN Society OASIS Guidance Document – rev.07/2006
For a more detaled definitions of staging for pressure ulcers please visit the National Pressure Ulcer Advisory Panel website.
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