Pressure Injury Classification (NPIAP, 2019)

Use the staging system below to categorize the injury appropriately. Wounds should be staged based on the deepest area. Note: Changing the stage as healing occurs, or reverse staging, is not a recommended practice (Berlowitz, 2022a).

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

• Intact skin with a localized area of non-blanchable erythema; may look different in dark pigmented skin.
• Blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
• Does not include purple or maroon color changes; these may indicate deep tissue pressure injury.

• Wound bed is viable, pink or red, moist, and may be intact or a ruptured serum-filled blister.
• Adipose (fat) and deeper tissues are not visible; granulation tissue, slough and eschar are not present.
• Commonly results from adverse microclimate and shear in the skin over the pelvis and heel.

• Adipose (fat) is visible in the ulcer; granulation tissue and epibole (rolled wound edges) are present.
• Slough and/or eschar may be visible; if slough/eschar covers the entire wound base, this is an unstageable pressure injury.
• Undermining and tunneling may be present.
• Depth of tissue damage varies by anatomical location (areas high in adipose may develop deep wounds).
• Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.

Stage 4 Pressure Injury: Full thickness skin and tissue loss

• Exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer is present.

• Slough or eschar may be present; if slough/eschar covers the entire wound base, this is an unstageable pressure injury.
• Epibole, undermining and tunneling often occur which may underestimate the extent of the injury.
• Depth of tissue damage varies by anatomical location (areas high in adipose may develop deep wounds).
• Ulcers located on the bridge of nose, ear, occiput, and malleus may be shallow as these areas do not have subcutaneous tissue (Berlowitz, 2022a).

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss

• Full thickness tissue loss; extent of tissue damage cannot be confirmed because base of the ulcer is covered by slough and/or eschar.
• If slough or eschar is removed, a Stage 3 or 4 pressure injury will be revealed.
• Stable (dry, adherent, intact) eschar on the heel or ischemic limb should not be softened or removed.

Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration

• Intact or non-intact skin with area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.
• Pain and temperature change often precede skin color changes.
• Discoloration may appear differently in darkly pigmented skin.
• Injury results from intense and/or prolonged pressure and shear forces between bone and muscle.
• If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or stage 4).
• This stage should not be used to describe vascular, traumatic, neuropathic, or dermatologic conditions.
• May be difficult to detect in patients with dark skin; assess for painful, firm or spongy, boggy, warm, or cool skin compared with the surrounding tissue (Berlowitz, 2022a).

• Results from devices used for diagnostic or therapeutic purposes.
• Injury generally takes the pattern or shape of the device and should be staged using the staging system.

• Found on mucous membranes with prior medical device use at the location of the injury.
• Due to the anatomy of the tissue, these ulcers cannot be staged using the NPIAP staging system.

Pressure Injury Prevention

General Skin Care (Berlowitz, 2022b; NPIAP, 2019)

• Obtain patient history: assess for connective tissue disorders and other chronic diseases, previous surgeries, and factors limiting mobility; current medications, allergies, past therapies (radiation or chemotherapy) and tobacco and alcohol use.
• Perform physical examination: inspect all areas of the skin as soon as possible upon admission for signs of pressure injury, especially non-blanchable erythema.
  • Examine entire skin surface for pressure ulcers, epidermal excoriations, rashes, maceration, edema, and old scars.
  • Assess skin temperature, color, turgor, moisture, and integrity. Record any changes as soon as they are identified.
  • In darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent skin.
• Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters and elbows, and beneath medical devices.
• Cleanse skin promptly after episodes of incontinence.
• Use skin cleansers that are pH balanced for the skin; avoid hot water.
• Avoid disturbing stable, hard, dry eschar in ischemic limbs or heels unless infection suspected.
• Apply skin moisturizers daily on dry skin.
• Apply a barrier product to protect skin from moisture.
• Avoid vigorous massage over bony prominences.
• Avoid positioning the patient on an area of erythema or pressure injury.

• Use a valid tool to assess the patient’s risk for malnutrition.
• Assess oral, enteral and parenteral intake and refer at-risk patients to a registered dietitian/nutritionist; assessment includes protein and caloric intake, hydration status, serum albumin and/or prealbumin, and total lymphocyte count.
• Support patients with adequate fluid intake and a balanced diet and correct any nutritional deficiencies.
• Assess adequacy of oral, enteral, and parenteral intake. Target protein intake is 1.25 to 1.5 g/kg/day.
• Assess weight changes over time.
• Nutritional supplements are only recommended when deficiencies are present, or if nutritional intake is not optimal.

• When possible, encourage mobility.
  • Immobilized patients may benefit from physical therapy.
  • Limit sedatives that contribute to immobility.
  • In critically ill patients, reposition using slow, gradual turns to allow time for stabilization of hemodynamic and oxygenation status.
• Turn and reposition all at-risk patients, unless contraindicated; schedule frequency based on the support surface in use, the tolerance of skin for pressure and the patient’s preferences.
  • General recommendation is to reposition at least every two hours.
  • Chair-bound patients who are weak or immobile should be repositioned every hour.
  • Lengthen the turning schedule at night to allow the patient to sleep.
• When turning, place the patient in a ≤ 30-degree side lying position, and ensure the sacrum is off the bed.
• Assess the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the patient when choosing a support surface.
• Continue to reposition the patient when placed on any support surface.
• Use a breathable incontinence pad when using microclimate management surfaces.
• Use pressure redistributing cushions for patients sitting in chairs or wheelchairs.
• If the patient cannot be moved or is positioned with the head of the bed elevated over 30 degrees, place a polyurethane foam dressing on the sacrum.
• Place pillows or foam wedges between the ankles and knees if patients have no mobility in these areas.
• Elevate heels off bed or use polyurethane foam dressings on patients at high-risk for heel ulcers.
• Place thin foam or breathable dressings under medical devices.
• Encourage mobility, provide physical therapy, and limit sedative medications, if possible.