Chapter 15 Skin Integrity

TABLE 15.1 cont. Pressure Ulcer Stages/Categories Category/Stage

Illustration

Category/stage IV: full thickness tissue loss

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Description

Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a category/stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue, and these ulcers can be shallow. Category/ stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

Additional Categories/Stages for the United States

Unstageable/ unclassified: full thickness skin or tissue loss— depth unknown

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a category/stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Suspected deep tissue injury: depth unknown

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

aBruising indicates deep tissue injury.

Source: Reprinted with permission from National Pressure Ulcer Advisory Panel. Pressure ulcer staging/category illustrations. www. npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/. Accessed January 25, 2016.