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Pressure Injury Staging

My first-ever clinical exposure to a pressure injury happened about 30 years ago, when I was a paramedic. We transported a patient from a nursing home to a hospital. After getting his vital signs, I did a quick skin survey, and saw two huge holes over his hip bones. I asked the senior medic about it, and he explained that it was a pressure ulcer. He went on to explain the “Pressure Ulcer Staging System,” which was new to me then. This system was again explained to me in med school, again in residency, and again during my wound care training. In fact, it hasn’t changed much over the years. The first system was put out in 1955 by Dr. Guttmann, then further refined in 1975 by Dr. Shea. The “Shea System” most closely resembles what we have today. 

There have been refinements, and most people now refer to the National Pressure Ulcer Injury Advisory Panel ( for guidance. The basics of the system are a way to visually describe how bad a pressure ulcer is. In other words, just how bad of an injury were those holes I saw in my patient’s skin? 

For a lightning quick overview (we will come back to this in depth), a Stage 1 Pressure Injury is one where the skin has been negatively impacted by pressure, but there is no skin breakdown. In Stage 2, skin breakdown has begun. In Stage 3, the layers below the skin are visible, or there is dead tissue present. In Stage 4, the muscle layer or deeper layers are visible. 

The problem with the Pressure Injury Staging System as it is used, is that it is often used incorrectly. When used as a descriptive, as in, “That bedsore is a Stage 2 Pressure Injury,” then it can be very useful. When all providers use the same terminology, confusion is avoided. The problem comes when people make the natural assumption that all Pressure Injuries start as a Stage 1, progress to Stage 2, etc. In fact, this is exactly what I was taught by my Paramedic Captain back in 1990, because that is what he was taught, and that’s what we thought about Pressure Injuries for a long time. Even today, there are state laws that are based on this assumption. It happens to be completely false. 

We will circle back to Pressure Injuries in many future posts, but for now, at least understand that Pressure Injury staging is useful for description only, and does not imply that all ulcers happen in a standard manner, first you see this, then this, etc. Like everything else it Wound Care, it’s way more complex than that. 

For a good overview of the history of Pressure Injury Staging, see this link:

-Tim Lapham, MD, CWS-P

Tim Lapham, MD, CWS-P

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