Pressure Ulcer Definition by International NPUAP-EPUAP

A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.

Stage 1

Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
 
 

Stage 2

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

 

Stage 3
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.

 

Stage 4

Full-thickness tissue loss in which the base of the ulcer is covered slough(yellow, tan, grey, green or brown) and/or eschar(tan, brown or black) in the wound bed.

 

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.   

 

Deep Tissue Pressure Injury

Intact or non-intact skin with localized 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.