Pressure Injury Staging and Documentation
Pressure injury documentation records the stage, location, size and the prevention plan. In the United States, staging usually follows the National Pressure Injury Advisory Panel (NPIAP) system.
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The stages
- Stage 1: intact skin with a localised area of non-blanchable erythema
- Stage 2: partial-thickness skin loss with exposed dermis
- Stage 3: full-thickness skin loss; fat may be visible, but not fascia, muscle, tendon, ligament, cartilage or bone
- Stage 4: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone
- Unstageable: full-thickness loss obscured by slough or eschar
- Deep tissue pressure injury: persistent non-blanchable deep red, maroon or purple discolouration
NPIAP also describes medical device-related and mucosal membrane pressure injuries. Check the current definitions on the NPIAP site and follow your facility's classification.
Do not reverse-stage
A healing Stage 3 is documented as a healing Stage 3, not as a Stage 2. Healing is shown through measurements and tissue description.
Risk and prevention
Record the risk assessment tool your facility uses and its score, then document prevention: repositioning, support surfaces, heel offloading, moisture management and nutrition referral.