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RISK/WOUND GUIDELINES
"Pressure Ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear" (NPUAP, EPUAP, PPPIA, 2014).*
HIGH RISK CATEGORY/STAGE III - IV
MEDIUM RISK CATEGORY/STAGE I - II
LOW RISK CATEGORY/STAGE I
| Stage I: | Intact skin with non-blanchable redness of localized area usually over a bony prominence. |
| Stage II: | Partial thickness skin loss (or blister) presenting as a shallow open ulcer with a red pink wound bed. |
| Stage III: | Full thickness skin loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. |
| Stage IV: | Full thickness tissue loss with exposed bone, tendon or muscle - e.g. fascia, tendon or joint capsule. Often includes undermining and tunneling. |
*National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.
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