The Four Stages of Pressure Ulcers

Apr 07, 2017

Like most injuries to the human body, pressure ulcers, also called bedsores, may present symptoms of ranging severity.  Unlike other injuries, there are four stages of pressure ulcers that include detailed information about the wound type and severity, and are used to determine the best course of treatment.  It is important to understand the basics of the four stages of pressure ulcers, especially if you have a loved one in any of the following situations:

  • A loved one residing n a nursing home
  • A loved one admitted to a hospital or rehabilitation facility for an extended period of time
  • A loved one who has limited mobility, or who is confined to a bed or wheelchair

If any of these situations sounds relevant to you, read on to learn more about the four stages of pressure ulcers and what you can do to prevent illness and injury.

The Four Stages of Pressure Ulcers

Pressure ulcers have plagued healthcare systems around the world for centuries.  In fact, pressure ulcers have been discovered on Egyptian mummies dating more than 5,000 years old.  As far back as the 18th and 19th centuries, researchers were studying these wounds to determine how best to prevent and treat them.

Unfortunately, even with generations worth of information and knowledge, today’s healthcare system continues to be plagued by pressure ulcers as one of the most common preventable injuries sustained by patients in hospitals or nursing homes.

The National Pressure Ulcer Advisory Panel (NPUAP) identifies these pressure ulcers in 4 stages, which are:

  • Stage 1: The skin around the wound is intact, but may be painful, red, swollen, or warm/cool to the touch compared to surrounding skin. Stage 1 sores may be more difficult to identify on patients with darker skin tones, as blanching (color loss upon pressure) may not be as noticeable.
  • Stage 2: A shallow wound is present with redness in the center, or accompanied by a fluid-filled blister. Wound may be dry or shiny, but generally does not include discharge.  Stage 2 pressure ulcers may include a thinning or wearing away of the skin, which may create a crater.
  • Stage 3: Wound penetrates skin and underlying tissue, and subcutaneous fat may be visible. Stage 3 wounds do not penetrate to the muscle or bone, but may tunnel away from the wound.  The depth of Stage 3 pressure ulcers depends on the anatomical location.
  • Stage 4: Tissue loss is severe, with loss of skin and subcutaneous fat. At Stage 4 the muscle and bone are visible.  Stage 4 pressure ulcers may extend outside the wound to surrounding tissue, tendons, or fascia.  Slough and discharge is present, and the wound may have a smell.

Two Stages Beyond

The NPUAP did intensive research between 2001 and 2007, at which point they added two additional stages of pressure ulcers designed to address what happens to the pressure ulcer wound beyond stage 4.  These stages are identified as deep tissue injury and unstageable.  A more detailed description of these two additional stages includes the following:

  • Deep Tissue Injury: A deep tissue injury (DTI) occurs when a pressure sore develops, but there is no visible breaking to the skin above it. There may be bruising or discoloration, a blood-filled blister, or other symptom, but these injuries are not as obvious as those beginning on the skin.  Deep tissue injuries are extremely dangerous and can quickly lead to infection or spread to other parts of the body if not treated in a timely manner.
  • Unstageable: An unstageable pressure ulcer is an ulcer that has no clear, identifiable stage like those mentioned previously. Unstageable pressure ulcers may be covered with a thick layer of tissue, pus/discharge, or slough.  Skin discoloration and these factors make it difficult for the doctor to see the base of the wound to determine the stage.

Treating the Stages of Pressure Ulcers

Like any wound, treatment for a pressure ulcer depends on the severity and location of the wound.  Some of the most commonly used treatment options include:

  • Dressings: Applying dressings promotes healing and prevents infection. Dressings should be properly applied and routinely changed and cleaned.
  • Debridement: Debridement is the process of removing damaged tissue. There are a few different types of debridement that may be used, which are:
    • Surgical – Cuts away damaged tissue.
    • Mechanical – Pressurized irrigation that emits a low-frequency mist to loosen and remove damaged tissue.
    • Autolytic – Best for smaller wounds, this treatment uses special dressings that enhance the patient’s natural enzyme process to breakdown tissue.
    • Enzymatic – Applies chemical enzymes via specialized dressings, which breaks down damaged tissue.
  • Medication: Medications may be used to manage pain, either orally or topically, depending on the treatments being used. Medications like antibiotics may also be administered orally or topically to address infection.
  • Vacuum-Assisted Closure (VAC): This treatment uses a vacuum device that puts negative pressure on a wound in order to clean it and promote healing.
  • Surgery: In severe cases, pressure ulcers may require surgical treatment beyond debridement. In such cases, the damaged or dead tissue, and any surrounding injured tissue is surgically removed.  A skin, muscle, or tissue flap reconstruction may be performed to cover the area and protect the underlying structures.

It should be noted that use of any of these treatment methods depends on the nature and severity of the pressure ulcer, and what is best for you based on your overall health and diagnosis.

Preventing Pressure Ulcers

Hospitals and nursing homes have a variety of tools at their disposal to prevent development of pressure ulcers.  There are also an increasing number of innovative items being researched and tested, which could provide significant aid in preventing these often preventable wounds.

The most common method of preventing pressure ulcers from occurring is to reduce pressure placed on patients.  This includes:

  • Repositioning to ensure that the patient’s weight is evenly distributed to reduce friction and shear.
  • Supportive surfaces are also helpful, such as special mattresses, cooling pads, cushions, etc.
  • Hygiene is another crucial part of preventing pressure ulcers. Patients with limited mobility should be assisted in keeping skin clean and dry, inspecting for soreness or injuries, and keeping linens and bedding clean and free from debris.

Most pressure ulcers can be prevented with proper care.  Negligence on the part of healthcare providers, nursing homes, caregivers, and medical staff is one of the most commonly reported causes of pressure ulcers.  When negligence causes injury to you or someone you love, it is important that you explore your legal rights right away.  You may have the option of filing a pressure ulcer lawsuit to compensate you for injuries and losses, and hold accountable negligent parties.