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Understanding the Six-Stage Pressure Ulcer Classification System

This guide explores the six-stage pressure ulcer classification system recommended by AHRQ, NPUAP, and WOCN, highlighting its importance in clinical practice. Stage I involves non-blanchable erythema of intact skin, often over bony prominences, while reactive hyperemia represents a temporary reddening that resolves quickly. Deep tissue injury is characterized by maroon or purple tissue, requiring careful evaluation to distinguish between the various types. Understanding these stages can aid healthcare providers in effective documentation and management of pressure injuries.

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Understanding the Six-Stage Pressure Ulcer Classification System

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  1. ??? HOW ??? • The staging system currently recommended by AHRQ (AHCPR), NPUAP and WOCN (and accepted by Medicare) is a six-stage system based on the tissue layers involved

  2. LOOK FAMILIAR? NOW YOU KNOW WHY THERE WAS A REASON YOU MEMORISED THIS

  3. Stage I •  Defined area of non-blanchable erythema of INTACT skin (vs. reactive hyperemia) usually over a bony prominence. Pigmented skin may not have visible blanching; its color may differ from surrounding area.The area may be painful, firm, soft (boggy) warmer or cooler than adjacent tissue. (NOT eschar)

  4. Take home Words? Intact Non-blanchable Non-necrotic Boggy And think…..?pressure point?

  5. Reactive Hyperemia • is the red skin color that is normally observed once pressure to an area has been relieved. This type of hyperemia is blanchable and will resolve in approximately 1/2 to 3/4 the amount of time that the area was exposed to pressure. (Increased blood supply to clear away byproducts of ischemia) e.g. a patient who is repositioned Q 2H may experience this over a bony prominence for as long as 11/2 hours following the position change.

  6. Reactive Hyperemia • Stand up: look at your fingers, your neighbor’s crossed ankles , a leaned-upon elbow, and if you ask very politely, posterior thigh at chair edge • This is a normal process and should not be misclassified as a Stage I pressure ulcer.

  7. Deep Tissue Injury • Manifested as deep red, maroon, purple tissue or blood-filled blister. Epidermis may or may not be intact and usually sloughs off. • Usually results from pressure/shear • NOT to be confused with Stage I

  8. CAUTION • Be careful about charting “red sacrum” : Is it • Hyperemia? • Stage I? • Scar? • Deep Tissue Injury?

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