Staging Pressure Ulcers

Question 1

Stage I

Answer 1

• Intact, non-blanching erythematous area

- Indicates potential for ulceration

Question 2

Stage II

Answer 2

• Interruption of epidermis, dermis, or both

- Presents as abrasion, blister, or very shallow crater

Question 3

Stage III

Answer 3

• Full-thickness crater involving damage and/or necrosis down to, but not penetrating, fascia

Question 4

Stage IV

Answer 4

• Full thickness, similar to stage III, but penetrating fascia with involvement of muscle and bone
• May involve undermining

Question 5

Note: (Stave V)

Answer 5

Ulcers that are covered with eschar (a dry, dark scab or falling away of dead skin) and cannot be staged without debridement are sometimes called Stage V