Pressure Injury Stages

Stage 1:

The top layer of the skin remains unbroken, however it appears red and does not turn white when you press and remove your finger. For a dark-skinned person, the skin may appear as a different colour, for instance, as a dark blue or purplish spot.

Stage 2:

There is damage to the top layer of the skin, leaving an open wound. It may also look like a blister filled with clear fluid or pus.

Stage 3:

The injury extends into the tissue beneath the skin, forming a small crater. The fat layer may be seen, but not muscle, tendon, or bone.

Stage 4:

The injury extends further, forming a large crater. The deeper tissues, tendons, and bone may be visible.

Unstageable Pressure Injury:

The affected area is covered by a thick layer of dead skin and pus that may be yellow, grey, green, brown, or black. The dead skin makes it hard to tell how deep the injury is. This type of pressure injury is termed as an ‘unstageable’ pressure injury.

Deep Tissue Pressure Injury:

The tissues under the skin have been damaged, although there is no open wound. The skin may look purple or dark red, or there may be a blood-filled blister.

Medical Device Related Pressure Injury:

A medical device related pressure injury is injury to the skin caused by prolonged pressure/ friction/ shear from a medical device, such as a respiratory mask or tubing, cast, or feeding tube. The pressure injury tends to take on the pattern or shape of the medical device.

Mucous membranes (the moist lining of body cavities, such as the mouth and nose) are particularly prone to such pressure injuries. Greater care should be taken to avoid pressure/ friction/ shear from medical devices at these areas.

Medical device related pressure injuries can also be classified by severity (i.e. stage 1 to stage 4, unstageable pressure injury, or deep tissue pressure injury).

Pressure Injuries can also be caused by medical devices:

Respiratory Mask

Respiratory Tubing

Cast

Feeding Tube