This document provides an overview of pressure injuries and other wounds. It summarizes the changes made in 2015 by NPUAP to the pressure injury staging system, replacing Roman numerals with Arabic numerals and changing the term "pressure ulcer" to "pressure injury". Stage 1 is now defined as intact skin with non-blanchable erythema. Stage 2 involves partial skin loss exposing dermis. Stage 3 shows full skin loss exposing subcutaneous fat. Stage 4 penetrates deeper to expose fascia, muscle or bone. An unstageable injury has obscured tissue loss. Deep tissue injuries present as discolored intact skin. Medical device and mucosal membrane injuries are also described. Non-pressure issues like venous, arterial and

1. Pressure Injuries
and Other Wounds
[updated 2017]

2. Warning :
This presentation contains
graphic pictures of wounds

3. NPUAP Formed Task Force January
2015
damaged soft tissue now labeled as
“pressure injury” replacing “pressure ulcer.”
because the term “injury” was more inclusive of
all 6 stages.
Change from Roman to Arabic numerals
Example: Stage ii is now Stage 2
Medical Device Related Pressure Injury
Mucosal Membrane Pressure Injury
What’s New?

4. localized damage to the
skin and underlying soft
tissue usually over a bony
prominence or related to a
medical or other device.
Can present as intact skin
or an open ulcer and may
be painful.
What is a Pressure Injury ?

5. a result of intense and/or prolonged pressure or
pressure in combination with shear.
What is a Pressure Injury ?

6. Diabetes
Anemia
Nutritional State
Weight Loss
Coagulopathy
Multiple comorbidities
Incontinence
Lack of mobility
Intrinsic FactorsIntrinsic Factors

7. Pressure Injury Staging:Pressure Injury Staging:
Healthy SkinHealthy Skin

8. Stage 1 Pressure InjuryStage 1 Pressure Injury

9. Stage 1 Definition :tage 1 Definition : OldOld vs.vs. NewNew
Old Stage I Pressure Ulcer :
Non-blanchable erythema
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 1 may be difficult to detect in
individuals with dark skin tones
New Stage 1 Pressure Injury:
Non-blanchable erythema of intact
skin
Intact skin with a localized area of
non-blanchable erythema, which
may appear differently in darkly
pigmented skin.
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 injury.

10. Updated Stage 1 Definition :tage 1 Definition :
Intact skin with a localized area of non-
blanchable erythema, which may appear
differently in darkly pigmented skin.
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 injury.

12. Stage 1 pressure areas can
develop in as short as 30
minutes
Boggy
He
Cocc
yx

14. Stage 2 Definition :Stage 2 Definition : OldOld vs.vs. NewNew
Old 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 or sero-
sanguineous filled blister.
Presents as a shiny or dry shallow
ulcer without slough or bruising*.
This category should not be used to
describe skin tears, tape burns,
incontinence associated dermatitis,
maceration or excoriation.
*Bruising indicates deep tissue
injury
Stage 2 Pressure Injury:
Partial-thickness loss of skin with
exposed dermis. The wound bed is
viable, pink or red, moist, and may
also present as an intact or ruptured
serum-filled blister.
Adipose (fat) is not visible and
deeper tissues are not visible.
Granulation tissue, slough and
eschar are not present. These
injuries commonly result from
adverse microclimate and shear in
the skin over the pelvis and shear in
the heel.
This stage should not be used to
describe moisture associated skin
damage (MASD) or traumatic
wounds(skin tears, burns, abrasions).

15. Updated Stage 2 Definition :Updated Stage 2 Definition :
Stage 2 Pressure Injury:
Partial-thickness loss of skin with exposed dermis.
The wound bed is viable, pink or red, moist, and may
also present as an intact or ruptured serum-filled
blister.
Adipose (fat) is not visible and deeper tissues are not
visible. Granulation tissue, slough and eschar are not
present. These injuries commonly result from adverse
microclimate and shear in the skin over the pelvis and
shear in the heel.
This stage should not be used to describe moisture
associated skin damage (MASD) or traumatic
wounds(skin tears, burns, abrasions).

16. On dark
pigmented
skin
On fair
skin
bliste
r
Stage 2
Presentations

17. Moisture associated
Skin Damage
Moisture associated
Skin Damage
Incontinence Associated DermatitisIncontinence Associated Dermatitis
Not Stage 2..

21. Stage 3 Definition :Stage 3 Definition : OldOld vs.vs. NewNew
Old 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 (adipose)
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 3 Pressure Injury:
Full-thickness loss of skin, in which
adipose(fat) is visible in the ulcer and
granulation tissue and epibole(rolled
wound edges) are often present.
Slough and/or eschar may be visible.
The depth of tissue damage varies
by anatomical location; areas of
significant adiposity can develop
deep wounds. Undermining and
tunneling may occur. Fascia, muscle,
tendon, ligament, cartilage and/or
bone are not exposed. If slough or
eschar obscures the extent of tissue
loss this is an Unstageable pressure
Injury.

22. Updated Stage 3 Definition :Updated Stage 3 Definition :
Stage 3 Pressure Injury:
Full-thickness loss of skin, in which adipose(fat) is
visible in the ulcer and granulation tissue and
epibole(rolled wound edges) are often present. Slough
and/or eschar may be visible. The depth of tissue
damage varies by anatomical location; areas of
significant adiposity can develop deep wounds.
Undermining and tunneling may occur. Fascia,
muscle, tendon, ligament, cartilage and/or bone are
not exposed. If slough or eschar obscures the extent
of tissue loss this is an Unstageable pressure Injury.

23. 
Stage 3 with UnderminingStage 3 with Undermining

26. Stage 4 Definition :Stage 4 Definition : OldOld vs.vs. NewNew
Old Stage Iv Pressure Ulcer
Full thickness tissue loss with
exposed bone, tendon or muscle.
Slough or eschar maybe present.
Often includes 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 (adipose) 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 or
osteitis likely to occur. Exposed
bone/muscle is visible or directly
palpable.
Stage 4 Pressure Injury:
Full-thickness skin and tissue loss
with exposed or directly palpable
fascia, muscle, tendon, ligament,
cartilage or bone in the ulcer. Slough
and/or eschar may be visible.
Epibole(rolled edges),undermining
and/or tunneling often occur. Depth
varies by anatomical location. If
slough or eschar obscures the extent
of tissue loss this is an
Unstageable Pressure Injury.

27. Updated Stage 4 DefinitionUpdated Stage 4 Definition
Stage 4 Pressure Injury:
Full-thickness skin and tissue loss with exposed or
directly palpable fascia, muscle, tendon, ligament,
cartilage or bone in the ulcer. Slough and/or eschar
may be visible. Epibole (rolled edges),undermining
and/or tunneling often occur. Depth varies by
anatomical location. If slough or eschar obscures the
extent of tissue loss this is an Unstageable Pressure
Injury.

28. ReadyReady ??

32. If you can seeIf you can see
or feelor feel anyany
cartilagecartilage in thein the
wound,wound,
it isit is a Stage 4a Stage 4
pressure injury.pressure injury.

34. Unstageable Definition :Unstageable Definition : OldOld vs.vs. NewNew
Old Unstageable Pressure
Ulcer: •Full thickness tissue loss in
which actual depth of the ulcer is
completely obscured 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 are removed
to expose the base of the wound,
the true depth cannot be
determined; but it will be either a
Stage III or IV. 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.
Unstageable Full-Thickness
Pressure Injury:
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. If slough or eschar is s
removed, a Stage 3 or Stage 4
pressure injury will be revealed.
Stable eschar( i.e. dry, adherent,
intact without erythema or fluctuance)
on an ischemic limb or the
heel(s)should not be softened or
removed.

35. Updated Unstageable Definition :Updated Unstageable Definition :
Unstageable Full-Thickness Pressure Injury:
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.
If slough or eschar is s removed, a Stage 3 or Stage
4 pressure injury will be revealed. Stable eschar( i.e.
dry, adherent, intact without erythema or fluctuance)
on an ischemic limb or the heel(s)should not be
softened or removed.

36. Unstageable
presentations
Esch
ar
Slou
gh
Mixe

38. Deep Tissue Injury Definition :Deep Tissue Injury Definition :OldOld vs.vs. NewNew
Old DTI Ulcer: Purple or maroon
localized area of discolored intact
skin or blood-filled blister due to
damage of underlying soft tissue
from pressure and/or shear.
The area may be preceded by
tissue that is painful, firm, mushy,
boggy, warmer or cooler as
compared to adjacent tissue.
Evolution may include a thin blister
over a dark wound bed. The wound
may further evolve and become
covered by thin eschar. Evolution
may be rapid exposing additional
layers of tissue even with
optimal treatment
New 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.
Discoloration may appear differently
in darkly pigmented skin. This injury
results from intense and/or prolonged
pressure and shear forces at the
bone-muscle interface. The wound
may evolve rapidly to reveal the
actual extent of tissue injury, or may
resolve without tissue loss.

39. DTI
Presentations
Heel
Butt

41. Medical Device Related Definition:Medical Device Related Definition:OldOld vs.vs. NewNew
Old medical Devise
related pressure Ulcer:
Medical device
related pressure ulcers are
pressure ulcers that result
from the use of devices
designed and applied for
diagnostic or therapeutic
purposes. The resultant
pressure ulcer generally
closely conforms to the
pattern or shape of the
device.
New medical device related
pressure injury:
This describes an etiology.
Medical device related
pressure injuries result from
the use of devices designed
and applied for diagnostic or
therapeutic purposes. The
resultant pressure injury
generally conforms to the
pattern or shape of the device.
The injury should be staged
using the staging system.

43. Mucosal Pressure Definition:Mucosal Pressure Definition:OldOld vs.vs. NewNew
Old Mucosal pressure
Ulcer:
Mucosal Pressure Ulcers are
pressure ulcers found on
mucous membranes with a
history of a medical device in
use at the location of the
ulcer.
New Mucousal Membrane
pressure injury:
Mucosal membrane pressure
injury is found on mucous
membranes with a history of a
medical device in use at the
location of the injury. Due to
the anatomy of the tissue these
injuries cannot be staged

46. Wound
Heal i ng

47. New skin that is light
pink and shiny
In Stage 2 pressure ulcers,
epithelial tissue is seen in
the center and edges of the
ulcer.
In full thickness Stage 3 and
4 pressure ulcers, epithelial
tissue advances from the
edges of the wound.
Tissue Type:Tissue Type: EpithelialEpithelial

48. Red tissue
with
“cobblestone”
or bumpy
appearance
bleeds easily
when injured.
Does not have
any slough
Tissue type-Tissue type-GranulationGranulation

49. Non-viable yellow, tan, gray,
green or brown tissue;
usually moist, can be soft, stringy
and mucinous in texture.
Slough may be adherent to the
base of the wound or present in
clumps throughout the wound bed.
If slough is present in a pressure
injury-it is at a stage 3 or higher
Tissue Type:Tissue Type: SloughSlough

51. Dead or devitalized tissue
that is hard or soft in
texture
usually black, brown, or tan in
color, and may appear scab
like.
usually firmly adherent to the
base of the wound and often
the sides/ edges of the wound.
Presence of eschar is a stage 4
or higher
Tissue Type-Tissue Type-EscharEschar

52. Non-Pressure UlcersNon-Pressure Ulcers

53. Venous

54. Due to venous insufficiency
Medial Aspect of the leg
Beefy Red
Jagged
Painless
may start with some kind of
minor trauma
Does not typically occur over
a bony prominence
VenousVenous Ulcer CharacteristicsUlcer Characteristics

55. ArterialArterial
UlcersUlcers

56. Ischemia is the etiology but
pressure or trauma may be a
factor
frequently seen on the dorsum
(top) of the foot
Small, punctuated ulcers that are
usually well circumscribed
painful
Delayed capillary refill/pulse
Hairless extremities
skin is shiny, thin, dry, cold
ArterialArterial Ulcer CharacteristicsUlcer Characteristics

57. Usually occur on the bottom of the
foot.
May have discoloration in feet:
black, blue, or red
They precede over 80% of leg
amputations in the US
Diabetic Foot UlcersDiabetic Foot Ulcers

59. KennedyKennedy UlcersUlcers
Unique to
End of Life
Patients

60. usually starts on the sacrum
May start as a Stage 2 and
rapidly become a Stage 3
or 4
may be shaped like a pear,
butterfly or horseshoe with
irregular borders
colors of red, yellow, black
or purple.
The life expectancy of the
sudden onset presentation
can be within 8-24 hours.
KennedyKennedy Ulcers-CharacteristicsUlcers-Characteristics

61. KennedyKennedy UlcersUlcers
Ulcers shown developed in 3-4 hours

62. Other Skin Impairments
Moisture Associated Skin Damage

63. Urine
Stool - especially liquid stool
Perspiration
Effluent from an ostomy
Wound Exudate
Moisture SourcesMoisture Sources

64. Incontinence Associated Dermatitis

65. Intertriginous Dermatitis (Fungal

66. iwound Associated Dermatitis

68. Peri-stomal Dermatitis

70. Contributing Factors::Contributing Factors::
Skin CareSkin Care
Manage moistureManage moisture
keep skin clean/ drykeep skin clean/ dry
pH balanced cleanserpH balanced cleanser
manage incontinencemanage incontinence
protect from urine/stool/perspirationprotect from urine/stool/perspiration
Minimize friction and shearMinimize friction and shear
Lift sheet/devicesLift sheet/devices
LIFT –do not drag/pull up in bedLIFT –do not drag/pull up in bed

71. Contributing Factors:Contributing Factors: PositioningPositioning
Frequent TurningFrequent Turning
avoid positioning on area of erythemaavoid positioning on area of erythema
Use foam wedges for 30 degree lateralUse foam wedges for 30 degree lateral
positioningpositioning
Maintain sheets without creasesMaintain sheets without creases
Avoid multiple layers of incontinence paddingAvoid multiple layers of incontinence padding
Protect/offload heelsProtect/offload heels
Pressure Reducing Support Surface for bedPressure Reducing Support Surface for bed
or chairor chair

72. Preventing Heel UlcersPreventing Heel Ulcers
National Pressure Ulcer Advisory Panel (NPUAP) directive:
“Ensure that the heels are free of the surface of the bed.
Heel-protection devices should elevate the heel completely (offload them)
in such a way as to distribute the weight of the leg along the calf."
“Total heel offloading is the only effective method for heel ulcer
prevention."
“Heel ulcers are the most common facility-acquired pressure ulcer in long-
term acute care facilities and second most common pressure ulcer overall."

73. Patients at low risk for heel pressure
ulcers/skin breakdown (These devices do
NOT provide pressure relief!)

74. Patients at moderate to highPatients at moderate to high
risk for heel pressurerisk for heel pressure

75. Prophylactic DressingsProphylactic Dressings

76. Microclimate ControlMicroclimate Control
specialized surfaces that changespecialized surfaces that change
the rate of evaporationthe rate of evaporation

77. Electrical Stimulation of the MusclesElectrical Stimulation of the Muscles

78. TextilesTextiles
using silk-likeusing silk-like
fabrics rather thanfabrics rather than
cotton or cotton-cotton or cotton-
blend fabrics toblend fabrics to
reduce shear andreduce shear and
frictionfriction

79. TreatmentTreatment
1. Optimize the host response by:
evaluating nutritional status/deficits;
stabilizing glycemic control
improving arterial blood flow
reducing immunosuppressant therapy if
possible.
2. Prevent contamination of the pressure ulcer.
3. Reduce bacterial load and biofilm
4. Use non-toxic topical antiseptics for a limited
time period

80. WarningsWarningsHydrogen peroxide is highly toxic to tissues even at low
concentrations14, 15 and should not be used as a preferred topical
antiseptic. Its use should be totally avoided in cavity wounds due to
the risk of surgical emphysema and gas embolus.
Iodine products should be avoided in patients with impaired renal
failure, history of thyroid disorders or known iodine sensitivity.
Sodium hypochlorite (Dakin’s solution) is cytotoxic at all
concentrations and should be used with caution, at concentrations no
greater than 0.025%, for short periods only when no other appropriate
option is available.
There is a risk of acidosis when acetic acid is used for extended
periods over large wound surface areas.

81. TreatmentTreatment 5. Consider the use of
medical-grade honey in
heavily contaminated or
infected pressure ulcers until
definitive debridement is
accomplished.
•Caution: Before applying a honey
dressing, ensure the individual is
not allergic to honey. Individuals
who have bee or bee stings allergies
are usually able to use properly
irradiated honey products.

82. TreatmentTreatment 6. Limit the use of topical
antibiotics on infected
pressure ulcers, except in
special situations where the
benefit to the patient
outweighs the risk of
antibiotic side effects and
resistance.
•In general, topical
antibiotics are not
recommended for treating
pressure ulcers.

83. TreatmentTreatment
7. Use systemic antibiotics for
individuals with clinical evidence of
systemic infection, such as positive
blood cultures, cellulitis, fasciitis,
osteomyelitis, systemic
inflammatory response syndrome
(SIRS), or sepsis.

84. Selecting Wound DressingsSelecting Wound Dressings
Select a wound dressing based on the:
1. ability to keep the wound bed moist
2. need to address bacterial bio burden
3. nature and volume of wound exudate
4. condition of the tissue in the ulcer bed
5. condition of periulcer skin
6. ulcer size, depth and location
7. presence of tunneling and/or undermining
8. goals of the individual with the ulcer

85. Name
the
Stage..

87. Deep Tissue InjuryDeep Tissue 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.

89. Stage 2 Pressure Injury
Partial-thickness loss of skin with exposed
dermis. The wound bed is viable, pink or red,
moist, and may also present as an intact or
ruptured serum-filled blister.
Adipose (fat) is not visible
and deeper tissues
are not visible.
Granulation tissue,
slough and eschar
are not present.

91. Unstageble Full Thickness PressureUnstageble Full Thickness Pressure
InjuryInjury
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. If slough or
eschar is removed, a
Stage 3 or Stage 4
pressure injury
will be revealed.

93. Stage 3 Pressure InjuryStage 3 Pressure Injury
Full-thickness loss of skin, in which adipose(fat)
is visible in the ulcer and granulation tissue and
epibole (rolled wound edges) are often present.
Slough and/or eschar may be visible.

95. Deep Tissue Pressure InjuryDeep 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.

97. Stage 4 Pressure InjuryStage 4 Pressure Injury
Full-thickness skin and tissue loss with exposed
or directly palpable fascia, muscle, tendon,
ligament, cartilage or bone in the ulcer. Slough
and/or eschar may be visible..

99. Stage 1 Pressure InjuryStage 1 Pressure Injury
Non-blanchable erythema of intact skin
Intact skin with a localized area of non-
blanchable erythema, which may appear
differently in darkly pigmented skin.

100. Thank You !Thank You !

101. ResourcesResources
National Pressure Ulcer Advisory Panel
www.nupap.org
•2014 Prevention and Treatment of Pressure Ulcers:
Clinical Practice Guideline (Quick Reference Guide
available as FREE download)
Association for the Advancement of Wound
Care
•http://aawconline.org/
•http://bradenscale.com/
Wound, Ostomy, Continence Nurses
Societywww.wocn.org