What is the National Pressure Injury Advisory Panel (NPIAP) staging system for pressure injuries (pressure ulcers)?

Updated: Mar 26, 2020
  • Author: Christian N Kirman, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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The categories specified in the current NPIAP staging system are as follows [2] :

  • Stage 1 pressure injury - Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin; presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes; color changes do not include purple or maroon discoloration, which may indicate deep tissue pressure injury
  • Stage 2 pressure injury - Partial-thickness skin loss with exposed dermis; the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister; adipose (fat) and deeper tissues are not visible, and granulation tissue, slough and eschar are not present; these injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel
  • Stage 3 pressure injury - Full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present; slough or eschar may be visible; the depth of tissue damage varies by anatomic location; areas of significant adiposity can develop deep wounds; undermining and tunneling may occur; fascia, muscle, tendon, ligament, cartilage, and bone are not exposed
  • Stage 4 pressure injury - Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer; slough or eschar may be visible; epibole (rolled edges), undermining, and tunneling often occur; depth varies by anatomic location
  • Unstageable pressure injury - Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; if slough or eschar is removed, a stage 3 or 4 pressure injury will be revealed
  • Deep tissue pressure injury - Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister; pain and temperature change often precede skin color changes; discoloration may appear differently in darkly pigmented skin; the injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface

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