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New Pressure Ulcer Staging Guidelines
Michele Cournan, MS RN CRRN APRN-BC

Pressure ulcers are a major component of rehabilitation nursing. Pressure ulcer prevalence rates in acute care patients range from 14% to 17% (Whittington & Briones, 2004). Some of these ulcers start as benign and appear as purple discoloration or blisters. These types of ulcers are often ignored, or treated as if they are minor, but they can rapidly deteriorate into a large ulcer, exposing muscle fascia and bone. This has prompted the National Pressure Ulcer Advisory Panel (NPUAP) to release new pressure ulcer staging guidelines. It has been long believed that some Stage I ulcers are actually worse than Stage IV ulcers because the damage to underlying structures is clearly visible in a Stage IV ulcers, but the damage is hidden when the top layer of skin is intact, as in a Stage I ulcer (Figures 1–4). These new staging guidelines provide clinicians with a way to indicate that there is likely underlying tissue damage. It is vitally important that all nurses are able to stage wounds correctly to allow for proper treatment. Staging is for pressure ulcers only. Venous ulcers, diabetic ulcers, arterial ulcers, and skin tears should not be staged.

The following is a summary of the new staging guidelines available from the National Pressure Ulcer Advisory Panel.

Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or a blood-filled blister caused by damage to the underlying soft tissue. Area may be painful, boggy, mushy, firm, and warmer or cooler compared to adjacent skin. These ulcers may be difficult to detect in patients with dark skin tones. The area may evolve to be covered by a thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

About the Author

Michele Cournan, MS RN CRRN APRN-BC, is a clinical nurse specialist at Sunnyview Rehabilitation Hospital, Schenectady, NY. Address correspondence to her at cournanm@nehealth.com.


Pressure Ulcer Stages Revised by NPUAP. Retrieved August 20, 2007 from http://www.npuap.org/pr2.htm.

Whittington, K. T., & Briones, R. (2004). National Prevalence and Incidence Study: 6-year sequential acute care data. Advances in Skin and Wound Care, 17(9), 490–494.