Pressure Ulcer Management

In order to develop a plan of care for patients with pressure ulcers/injuries it is important for caregivers to understand the extent of tissue damage involved. This can be done by using a classification system. The following system can be used as a guide when assessing. Click the buttons or swipe to navigate through the slides.

What causes a pressure ulcer?

Skin can breakdown in hours
Timely assessment will prevent minor damage from becoming a major ulcer
Risk factors are predictable and at risk patients are easily identifiable
Wet skin is more vulnerable to skin breakdown, but dry skin can also be affected
Continued pressure, especially over bony prominences, increases risk

What are the Categories of Pressure Ulcer?

There are four categories of Pressure Ulcer.
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This allows caregivers to assess the amount of damage involved on visual inspection.

Category 1

Intact skin with non-blanchable redness of a localised area usually over a bony prominence.
Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area.
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Continued pressure, especially over bony prominences, increases risk

Category 1

Pressure Injury - Lightly Pigmented Skin

Category 1

Pressure Injury - Darkly Pigmented Skin

Category 1

Pressure Injury - Example

Category 2

Partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink woundbed, without slough.
May present as an intact or open/ruptured serum-filled blister.
Presents as a shiny or dry shallow ulcer without slough or bruising.

Category 2

Pressure Injury - Lightly Pigmented Skin

Category 2

Pressure Injury - Example

Category 3

Full thickness tissue loss.
Subcutaneous fat maybe visible but bone, tendon and muscle are not exposed.
Slough may be present but does not obscure the depth the depth of tissue loss. May include undermining and tunnelling.
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey,green or brown) and/or eschar (tan, brown or black) in the wound bed.
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined.

Category 3

Pressure Injury - Lightly Pigmented Skin

Category 3

Pressure Injury - Example

Category 3

Pressure Injury

Category 3

Pressure Injury

Category 3

Pressure Injury - Example

Category 4

Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar maybe present on some parts of the wound bed.
Often include undermining and tunnelling.

Category 4

Pressure Injury

Category 4

Pressure Injury - Example

Suspected Deep Tissue Injury

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.
The area may be precededby tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Deep tissue injury may be difficult in individuals with dark skin tones.

Suspected Deep Tissue Injury

Pressure Injury

Suspected Deep Tissue Injury

Pressure Injury - Example