Which stage of pressure injury is a shallow open with red pink wound bed?

Of course, no one ever enters a medical facility expecting to get sicker. Unfortunately, thousands of people who enter nursing homes and hospitals every year for medical treatment or rehabilitative care wind up developing a complication that is more painful and enduring than they ever could have imagined — the development of a pressure ulcer.

Pressure ulcers are wounds that frequently develop on bony areas of the body where there is little tissue to distribute the pressure from the surface that they are sitting or laying on over extended periods. For this reason, the most common areas of the body where pressure ulcers develop are: hips, elbows, heels and the area of the lower back known as the coccyx.

The medical community has embraced a staging system to grade pressure ulcers as they progress. The four stage scaling system uses identifiable characteristics present in various types of wounds to help professionals in the treatment of the pressure ulcers as well.

Which stage of pressure injury is a shallow open with red pink wound bed?

The National Pressure Ulcer Advisory Panel (NPUAP) has devised the most widely accepted pressure ulcer staging scale. Below are the guidelines as proposed by NPUAP:

Stage I Pressure Ulcer: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).

Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Stage III Pressure Ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable Pressure Ulcer: Full thickness tissue loss in which the base of the ulcer is covered 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 is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. 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.

Given the severity of pressure ulcer progression and ensuing complications, it is imperative that staff at medical facilities identify and begin a course of treatment as soon as there is evidence of a pressure ulcer in order to avoid the dibilitiating complications that typically accompany this condition.

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Pressure Injuries can develop quickly and often add a layer of complication to already complex medical conditions. Read more to learn how to identify and diagnose patients with stage I, II, III, and IV pressure injuries.

Have you ever heard the expression, “When you’re green, you’re growing. When you’re ripe, you rot.”? Well, picture what happens when you leave a piece of fruit, a peach for instance, in a bowl on the counter. Somehow, over the course of the week you forget about it, and when you return to eat it, you pick it up, only to find one side of the peach flattened and turned to mush, the skin bruised and perhaps broken in some spots.

Our skin can react in much the same way, with a condition known as pressure injuries (also pressure ulcers or bedsores). Pressure injuries can add another layer of complication onto already complex medical treatments, but the good news is, they’re also relatively easy to spot and usually preventable, you just have to know what you’re looking for.

What exactly is a pressure injury?

A pressure injury is defined as an injury to the skin and underlying tissue resulting from prolonged pressure. 

They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone, and are most common in patients with limited mobility such as the elderly, nursing home patients, patients in a coma, patients with reduced pain perception, and any patients who cannot move specific parts of their body.

In 2016 the National Pressure Ulcer Advisory Panel (NPUAP) amended the official name from “pressure ulcer” to “pressure injury” to more accurately reflect the fact that open ulceration does not always occur, and pressure injuries can describe both intact or ulcerated skin.

What causes pressure injuries?

There are many contributing factors for pressure injuries. At the most basic level, they result from three primary factors:

  • Sustained pressure. When skin and underlying tissue experience prolonged contact against a surface, the pressure may lead to insufficient oxygenation and damaged cells. This happens most often to areas that lack sufficient padding from muscle or fat, like heels, hips, shoulder blades, elbows, and the tailbone.
  • Friction. Friction occurs when skin is dragged across a surface. For instance, when a patient changes position or a care provider moves them. Friction is exacerbated when skin is moist.
  • Shear. Shear occurs when two surfaces move in opposite directions; for example, when a hospital bed is elevated, a patient may slide down, pulling bones and skin in different directions.

Why is it important to recognize pressure injuries?

Certainly, the primary reason for wanting to recognize and treat pressure injuries when they occur is for optimal patient care, but there is a secondary reason that should reinforce vigilance for all medical practitioners. In 2013 the National Quality Forum declared pressure injuries a “never event." Specifically, they stated that stage 3 and 4 pressure injuries that occur after admission to a healthcare facility are unacceptable and (given the proper care) unnecessary. This inclusion as a “never event” brought with it financial implications for pressure injuries – in the simplest of terms, the Centers for Medicare and Medicaid Services ruled that they can deny Medicare payment for hospital-acquired conditions that fall under the category of “never events,” making pressure injuries costly in more ways than one. (For more on pressure injuries and never events, read this post.)

The Four Stages of Pressure Injuries

We know pressure injuries are dangerous for our patients and costly for our medical system, so the question becomes, how can we recognize them in order to guard against them? Pressure injuries are broken into four stages, where the stage indicates the extent of tissue damage. Following are the key indicators for each stage.

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

In stage 1 pressure injuries the skin is still intact with a localized area of redness that does not turn white when pressure is applied (also known as non-blanchable erythema). Stage 1 does not include purple or maroon discoloration; these may indicate deep tissue pressure injury. For visual reference, see illustrations of pressure injuries from the NPUAP here.  

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis

In stage 2 pressure injuries there is a partial-thickness loss of skin with exposed dermis. The wound bed is pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Fat and deeper tissues are not visible. Connective granulation tissue and eschar (dark patches of dead skin) are also not present. Stage 2 injuries are a common result of an adverse microclimate (undesirable temperatures or skin surface moisture) and shear in the skin. For visual reference, see illustrations of pressure injuries from the NPUAP here.  

Stage 3 Pressure Injury: Full-thickness skin loss

Stage 3 pressure injuries involve full-thickness loss of skin, where fat tissue is visible and granulation tissue, rolled wound edges (epibole), and eschar may also be present. However, fascia, muscle, tendon, ligament, cartilage, and bone are not exposed. The depth of tissue damage may vary by anatomical location; areas with significant amounts of fat are at risk of developing deeper wounds. For visual reference, see illustrations of pressure injuries from the NPUAP here.  

Stage 4 Pressure Injury: Full-thickness skin and tissue loss

In stage 4, full-thickness skin and tissue loss has occurred, with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Rolled wound edges (epibole) and eschar may be present. Undermining and/or tunnelling can often occur (for more information on these conditions click here). As with stage 3 injuries, the depth and extent of damage may vary by anatomical location. For visual reference, see illustrations of pressure injuries from the NPUAP here.  

There are a few other pressure injury definitions; two are important here.

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

Unstageable pressure injuries occur when the extent of tissue damage within the ulcer cannot be ascertained because it is obscured by eschar for example. However, if the eschar  is removed, a stage 3 or stage 4 pressure injury will present. In these instances, the NPUAP advises that “stable eschar (i.e. dry, adherent, intact) on the heel or ischemic limb should not be softened or removed.”

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

A deep tissue pressure injury presents as (i) a localized area of persistent deep red, maroon, or purple discoloration that does not turn white when pressure is applied, or (ii) a separation revealing a dark wound bed or blood-filled blister. Pain and temperature change will often precede skin color changes. Discoloration may appear differently in darkly pigmented skin.

For more information on pressure injuries and preventive medicine, turn to MD at Home, the premier healthcare resource for primary care and geriatric medicine for homebound patients in the Chicagoland area.

What is stage 3 pressure injury?

Stage 3 bedsores (also known as stage 3 pressure sores, pressure injuries, or decubitus ulcers) are deep and painful wounds in the skin. They are the third of four bedsore stages. These sores develop when a stage 2 bedsore penetrates past the top layers of skin but has yet not reached muscle or bone.

What is a Stage 1 pressure injury?

Pressure injuries are described in four stages: Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose colour briefly when you press your finger on it and then remove your finger).

What are the 4 stages of pressure injuries?

These are:.
Stage 1. The area looks red and feels warm to the touch. ... .
Stage 2. The area looks more damaged and may have an open sore, scrape, or blister. ... .
Stage 3. The area has a crater-like appearance due to damage below the skin's surface..
Stage 4. The area is severely damaged and a large wound is present..

Is blanchable redness stage 1?

Stage 1 Pressure Ulcer/Injury: Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure ulcer/injury.