Clinical Pathways for the 5 Wound Types
Choose a wound type to view the associated clinical pathways and guidelines.
Pressure Ulcer Pathway
Pressure Ulcer:
Localized injury to the skin and/or underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear.
Stage I Wound
- Non-blanchable erythema of intact skin
Stage II Wound
- Partial thickness skin loss involving epidermis, dermis or both
- Superficial; may present as an abrasion, blister, shallow crater
- Non-blanchable dermis
Stage III Wound
- Full thickness tissue loss
- Subcutaneous fat may be visible but tendon, muscle or bone not exposed
- Slough may be present
- Undermining or tunneling may be present
Stage IV Wound
- Full thickness tissue loss
- Exposed tendon, muscle and/or bone
- Slough or eschar may be present
- Often has undermining or tunneling
Unstageable Wound
- Known but not stageable because of non-removable dressing/device -OR-
- Unstageable due to covering slough/eschar or deep tissue injury
Suspected Deep Tissue Injury
- Depth unknown
- Purple or maroon localized area of discolored intact skin
- Blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
References
Pieper, B. (2012). Pressure ulcers: impact, etiology, and classification. In R.A. Bryant and D.P. Nix (Eds.), Acute and chronic wounds. Current management concepts. Fourth edition. (pp122-136).St. Louis, MO: Elsevier Mosby
NPUAP-EPUAP International pressure ulcer prevention and treatment guidelines. http://www.npuap.org. Retrieved May 7, 2014.
