Four categories, plus unstageable and deep tissue injury
Expansion
Categories
| Category | Findings |
|---|---|
| 1 | Non-blanching erythema, skin intact |
| 2 | Partial thickness loss, shallow open ulcer or blister |
| 3 | Full thickness, subcutaneous fat visible, no bone, tendon or muscle |
| 4 | Full thickness with exposed bone, tendon or muscle |
| Unstageable | Base obscured by slough or eschar |
| Deep tissue injury | Purple or maroon intact skin, or a blood filled blister |
Common sites, at the bony prominences: sacrum, heels, ischial tuberosities, greater trochanters, elbows, occiput, ears, and under medical devices such as oxygen tubing, catheters, casts and cervical collars.
Risk factors: immobility, sensory impairment, poor nutrition and hydration, moisture from incontinence, friction and shear, poor perfusion, age, and previous pressure damage. The Waterlow and Braden scores formalise these.
SSKIN for prevention:
- S - Surface: appropriate mattress and cushion
- S - Skin inspection, at least daily, including under devices
- K - Keep moving: repositioning, usually two to four hourly
- I - Incontinence and moisture management
- N - Nutrition and hydration
Do not massage reddened areas, and do not turn a patient onto an area of existing damage.
Escalate if there is spreading erythema, malodour, exposed bone (osteomyelitis) or systemic sepsis. A category 3 or 4 pressure ulcer acquired in care is a reportable serious incident.