: Public <<enumeration>> Enumeration
Created: 3/23/2011 2:15:27 PM
Modified: 1/14/2013 10:36:29 AM
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Stage definitions were developed to guide clinical description of the depth of tissue destruction that occurs with pressure ulcers. <br /></p><p><br /></p><p>These definitions are taken from "National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System." Joyce Black, PhD, RN, CWCN, CPSN; Mona Baharestani, PhD, ANP, CWOCN, CWS, FAPWCA, FCCWS; Janet Cuddigan, PhD, RN, CWCN, CCCN; Becky Dorner, RD, LD; Laura Edsberg, PhD; Diane Langemo, PhD, RN, FAAN; Mary Ellen Posthauer, RN, CD, LD; Catherine Ratliff, PhD, APRN-BC, CWOCN; George Taler, MD. Urol Nurs. 2007;27(2):144-150. © 2007 Society of Urologic Nurses and Associates<br /></p>
Attribute
Public
  suspected deep tissue injury

Details:
Notes: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.  Reference: www.npuap.org
Constraints:
Vocabulary SNOMED CT: not found
 
Public
  stage I

Details:
Notes: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.  Reference: www.npuap.org
Constraints:
Vocabulary SNOMED CT: 421076008 Pressure ulcer stage 1 (disorder)
 
Public
  stage II

Details:
Notes: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.  It may also present as an intact or open/ruptured serum-filled blister. Reference:  www.npuap.org
Constraints:
Vocabulary SNOMED CT: 420324007 Pressure ulcer stage 2 (disorder)
 
Public
  stage III

Details:
Notes: Full thickness tissue loss.  Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed.  Slough may be present but does not obscure the depth of tissue loss.  It may include undermining and tunneling.  Reference:  www.npuap.org
Constraints:
Vocabulary SNOMED CT: 421927004 Pressure ulcer stage 3 (disorder)
 
Public
  stage IV

Details:
Notes: Full thickness tissue loss with exposed bone, tendon, or muscle.  Slough or exchar may be present on some parts of the wound bed.  It often includes undermining and tunneling. Reference:  www.npuap.org
Constraints:
Vocabulary SNOMED CT: 420597008 Pressure ulcer stage 4 (disorder)
 
Public
  unstageable

Details:
Notes: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound base.  Reference: www.npuap.org
Constraints:
Vocabulary SNOMED CT: 421594008 Nonstageable pressure ulcer (disorder)
 
Object Type Connection Notes
Pressure Ulcer Class Dependency