Pressure Injury Staging, Prevention, and Offloading
Staging (NPIAP)
- Stage 1: intact skin with non-blanchable erythema; in darker skin tones rely on color change, warmth, firmness, or pain.
- Stage 2: partial-thickness loss with exposed dermis, pink, moist, shiny; intact or ruptured blister; no slough, eschar, or fat.
- Stage 3: full-thickness loss with visible adipose, granulation, slough, or eschar; fascia, muscle, tendon, and bone are not exposed.
- Stage 4: full-thickness with exposed fascia, muscle, tendon, ligament, cartilage, or bone.
- Unstageable: base obscured by slough or eschar; remove it to stage.
- Deep tissue pressure injury (DTPI): intact or non-intact skin with persistent deep maroon or purple discoloration or a blood-filled blister; do not stage further until it declares itself. Mucosal membranes and moisture-associated skin damage are not staged.
Prevention and offloading
Use risk screening (Braden; 18 or below indicates risk), skin inspection each shift, repositioning on a written schedule, pressure-redistributing surfaces, heel suspension, moisture and incontinence management, and nutrition referral. Avoid donut devices and massaging reddened areas. Offload the site specifically: total contact casts and offloading boots for plantar foot ulcers, specialized cushions for seating.
Traps
- Calling intact purple skin Stage 1; it is a DTPI.
- Staging moisture-associated skin damage or incontinence dermatitis as pressure injury.
- Staging a wound containing slough as Stage 2.
- Expecting a Stage 4 to "become a Stage 3"; reverse staging is invalid.
- Debriding a stable, dry, intact heel eschar in severe arterial disease.
Rule of thumb
No fat, no Stage 3; no bone, no Stage 4. If the base cannot be seen, it is unstageable until debrided.