Classification of Pressure Ulcers
Definition of pressure ulcers— A localised injury to the skin and/or underlying tissue, usually over a bony prominence, resulting
from pressure, or pressure and shear.
Category 1—Nonblanchable
Intact skin with non– blanchable erythema
(redness ) of a localised area usually over a
boney prominence.
Category 3—Full thickness
skin loss
Full thickness tissue loss. Subcutaneous fat may
be visible but bone, tendon or muscle are not
exposed. Depth may vary depending on location
in body.
Category 2—Partial
thickness
Partial thickness loss of dermis presenting as a
shallow open ulcer with a red pink wound
without slough. Maybe intact or open blister
Category 4— Full thickness tissue loss
Full thickness tissue loss with exposed bone,
tendon or muscle. Slough may be present.
Depth may vary depending on location in
body.
Unstageable/ unclassified
Full thickness tissue loss, in which
the actual depth of the ulcer is
completely obscured by slough and or eschar in
the wound bed and no underlying structure is
visible. Should be categorised 3.
Suspected deep tissue injury
This is purple or maroon localised area
of discoloured intact skin or blood-filled
blister due to damage of underlying soft tissue
from pressure and/or shear. Can only be classified
once additional layers of tissues have been exposed. Can be category 2,3 or 4.
Differences between a pressure ulcer and moisture
Pressure Ulcer
Moisture Lesion
Further notes
Causes
Pressure and/ or shear must be present.
Moisture must be present (e.g. shinning, wet skin
caused by urinary incontinence or diarrhoea).
If moisture and pressure/shear are present. The lesion is then a
combined lesion. (report as moisture and pressure ulcer)
Location
A wound over a bony prominence
It may occur over boney prominence. Pressure and
shear should be excluded as causes. A moisture
lesion will be superficial often multiple must be in
an area where moisture is present due to
incontinence.
It is possible to develop pressure ulcers where soft tissue is
compressed ( e.g. by a nutritional tube, nasal oxygen tube, urinary
catheter)
Shape
Circular wounds or wounds with regular shape. If Diffuse, different superficial spots are more likely to Irregular wound shapes are often combined. The distinction
lesion is limited to one spot it is likely to be a
be moisture. In a kissing ulcer (copy lesion) at least between friction and pressure ulcer should be made based on histopressure ulcer.
one of the wounds is most likely to be moisture
ry and observation.
( urine, faeces, transpiration or wound exudate)
Depth
Category 2—Partial thickness skin loss (top layer
of skin). Category 3 or 4—full thickness skin loss
(all layers of skin).
Moisture lesion are superficial (partial thickness
skin loss). If infected it can be enlarged/ deepened.
Necrosis
Black necrotic scab = category 3 or 4.
No necrosis in a moisture lesion.
Necrosis soften up and changes colour but is never superficial. Distinction should be made between a black necrotic scab and a dried
up blood blister.
Edges
Edges to be distinct.
Diffuse or irregular edges.
Jagged edges seen in moisture lesions that exposed to friction.
Colour
Red skin, non-blanchable. Can have red in wound Red skin. Pink or white surrounding skin.
bed= category 2, 3 or 4. Yellow (softened
necrosis) in wound bed = category 3 or 4. Black in
wound bed = category 3 or 4.
Green in wound bed = infection.