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Evaluating pressure ulcers includes describing and documenting them and tracking their progress. Staging systems provide you with a guide in this process. The information in this sheet is an overview of the staging and treatment of pressure ulcers. Follow your facility’s specific guidelines.
Remember to: Assess, Describe, and Document
The unbroken skin is purple or maroon and looks bruised. Or there is a blood-filled blister. The area is painful, firm, mushy, boggy, warm, or cool to the touch. The cause of this skin change is pressure and/or shear, injuring the underlying soft tissue. The skin change could heal or progress to more severe stages of pressure ulcer.
Goal: Determine the extent of the injury, support blood flow, and prevent further breakdown of skin.
Prevent shear, friction, and moisture build-up.
Reassess the patient.
Manage pain of ulcer.
Assess for infection.
Discuss pressure ulcer with the physician.
The unbroken skin is red and nonblanchable. Note: It may be difficult to determine blanching in darker skin tones. The affected are may differ in color from the surrounding skin.
Goal: Prevent further progression of the ulcer and support blood flow.
Implement treatment plan for (Suspected) Deep Tissue Injury.
Cleanse and lightly moisturize the skin. Note: Never massage the affected area. This can cause further damage to tissue.
Apply protective dressing, if indicated.
Partial-thickness skin loss has occurred and the wound bed is red-pink in color. Slough is not present, but a broken or intact serum-filled blister may be evident.
Goal: Prevent full-thickness injury and continue to promote healing.
Implement treatment plan for previous stages.
Apply dressing to keep wound bed moist and promote healing.
Protect fragile skin from adhesives.
Reevaluate nutritional intake.
Full-thickness skin loss has occurred. Slough may be present. Subcutaneous fat may be visible, but bone, tendon, or muscle are not. Undermining or tunneling may also be present.
Goal: Maintain a clean, moist wound bed to prevent infection and promote new tissue growth (granulation).
Implement treatment plans for previous stages.
Remove dead tissue (debridement), if needed.
Fill the ulcer cavity with appropriate dressing.
Evaluate the need for nutritional consultation.
Full-thickness skin loss has occurred. Bone, tendon, or muscle is exposed. Slough or eschar may be present, but the base of the wound can be seen. Undermining and tunneling are often present.
Goal: Reduce drainage, remove dead tissue, and establish an environment for new tissue growth.
Confer with physician, if indicated.
Report bone involvement.
Treat infection with antibiotics, if indicated.
Discuss with physician whether surgery is needed.
Full-thickness skin loss has occurred. Slough or eschar covers the wound base. The wound depth cannot be determined because of the slough or eschar.
Goal: Determine stage, provide moist environment, and prevent further breakdown.
Debride the wound. Do not debride the heel unless signs of infection are present.
Reassess ulcer stage once base is visible.
Discuss pressure ulcer with physician.