NPIAP Staging for Pressure Injuries

Question 1

What is Stage 1?

Answer 1

Non-blanchable erythema of intact skin

Question 2

What is Stage 2?

Answer 2

Partial-thickness injury or serous/serosanguinous filled blister (intact or ruptured)

Question 3

What is Stage 3?

Answer 3

Full thickness, exposed adipose but NO exposed structures or cartilage (base must not be obscured)

Question 4

What is Stage 4?

Answer 4

Full-thickness with exposed or palpable underlying structures.

Question 5

What is a Deep Tissue Pressure Injury?

Answer 5

Intact or non-intact skin with signs of necrosis present; nonblanchable redness

(includes blood filled blister)

Question 6

When is a wound unstageable?

Answer 6

• Full thickness loss but with unknown depth.
• Base obscured by eschar or slough.

Question 7

When staging pressure injury, what stage occurs if wound gets better or worse?

Answer 7

If wound gets better, stage does not change!

• Once a pressure ulcer is staged, it cannot be backstaged

If a wound gets worse, stage can get worse.

• e.g can move from stage 3 to stage 4

“Modified” anything does not exist

Question 8

Fluid filled blisters would be in what stage?

Answer 8

Stage 2 (serous aero-sanguinous)

Question 9

Blood filled blister would be considered what stage?

Answer 9

Deep tissue pressure injury