NPUAP Stage 3 Pressure Injury, Most Pressure Ulcer Injury is Preventable With Proper Care and Pressure Relief
NPUAP Stage 3 Pressure Injury, Most Pressure Ulcer Injury is Preventable With Proper Care and Pressure Relief

NPUAP Stage 3 Pressure Ulcer Injury

Avoiding Nursing Home Pressure Ulcers – Pressure Ulcer Injuries

Nursing homes are established to provide the elderly with the assistance and care they need. In many instances, your loved one may become sick or bed ridden due to an accident or disease.

If your loved one is currently on bed rest or disabled, it is critical that they are receiving the adequate nursing care, including sufficient food and hydration as well as personal attention from the nursing home staff, to ensure they have adequate movement to shift the weight bearing locations on their bodies.

A lack of mobility leading to prolonged periods of time of increased pressure on a resident’s heels, lower back and shoulders can lead to ulcerations, often called decubitus ulcer, pressure ulcer or bed sores.

Pressure ulcers are often a sign that the nursing home staff is not assisting the residents to move freely or not turning them as they are meant to. This is a serious form of nursing home abuse that should be dealt with right away. Contacting a nursing home abuse lawyer is your first step against this type of mistreatment.

The Freedom from abuse, neglect and exploltation which regulation governs nursing homes considers pressure ulcers to Be “AVOIDABLE” and therefore preventable:

Pressure ulcers / sores. Based on the comprehensive assessment of a resident, the facility must ensure that—

(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and
(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Freedom from abuse, neglect and exploltation

Understanding Pressure Ulcers – Bed Sores

Bed sores also referred to as decubitus ulcers and pressure sores, are areas of damaged skin and tissue that develop due to a reduction in circulation often accompanied by excessive periods of unrelieved pressure on the affected area. In order to properly track the care provide for a pressure sore, it is essential that the staff understand the correct way to identify and chart the stages of pressure wounds.

National Pressure Injury Advisory Panel

The National Pressure Injury Advisory Panel (NPIAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research.

Pressure Ulcer Stages Revised by NPIAP

Pressure Ulcer Image Library

Pressure Ulcer Category / Staging Illustrations

Untreated Bedsore/Pressure Ulcer/Pressure Sore

The National Pressure Ulcer Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work is the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001.

The staging system was defined by Shea in 1975 and provides a name to the amount of anatomical tissue loss. The original definitions were confusing to many clinicians and lead to inaccurate staging of ulcers associated or due to perineal dermatitis and those due to deep tissue injury.

The proposed definitions were refined by the NPUAP with input from an on-line evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination. This process was completed online and provided input to the Panel for continued work. The proposed final definitions were reviewed by a consensus conference and their comments were used to create the final definitions. “NPUAP is pleased to have completed this important task and look forward to the inclusion of these definitions into practice, education and research”, said Joyce Black, NPUAP President and Chairperson of the Staging Task Force.

Pressure Ulcer – Pressure Injury Definition
A pressure ulcer – pressure injury is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

Pressure Ulcer Stages

Suspected Deep Tissue Injury:

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.

Further description:

Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Stage 1:

Intact skin with non-blanchable 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.

Further description:

The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk)

Stage 2:

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Further description:

Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury

Stage 3:

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Further description:

The depth of a stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage 4:

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Further description:

The depth of a stage 2 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.


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 bed.

Further description:

Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

For more information see National Pressure Injury Advisory Panel This organization is an excellent resource for caregivers and family members dealing with individuals that are at risk for pressure ulcers.

Bed sores are not always preventable but, in most instances, a nursing home staff should be aware of the pressure and wound building up around the area. It is the nursing staff’s duty to ensure that the elderly are looked after and this means ensuring they are moved and taken care of if the first stage of bed sores are present.

According to federal guidelines these type of pressure ulcers are “preventable” in most situations.

Make sure your loved on is getting the proper care including:

• Proper Hydration and Nutrition;
• Is getting turned or rotated every 2 hours if unable to get up from bed or from wheel chair;
• Sheets are keep clean and smooth (without wrinkles);
• A special pressure relieving mattress or wheel chair cushion is used;
• All wounds should be measured and evaluated (Staged from 1-4) using the “Braden Scale” or similar method;
• Wounds are immediately addressed in the early stages and appropriate wound care is performed by a qualified professional, including the use of wound vac devices and other methods to reduce the size and degree of the ulcers.

Questions to ask the Nursing Home regarding Pressure Ulcers:

• Request Nursing Home Policies regarding Pressure Ulcers.
• Was the sore acquired at the facility?
• Has the resident been assessed for Skin Breakdown Risks, what is the Braden scale staging? (Stages I-IV)?
• Does the nursing home have photos of the wound?
• Has the resident’s family and physician been notified that there is an ulcer?
• What was the resident’s treatment plan / care plan for the ulcer. Was there wound care?
• Was the wound care provided by the facility or outsourced?

Lastly, here are some additional resources for pressure ulcers information from the Minnesota Department of Health.

If you notice your loved one has bed sores, then it should act as a warning sign that the nursing staff may not be provided adequate health and personal care. You should contact a nursing home neglect attorney immediately to discuss your loved ones’ options. Attorney Kenneth L. LaBore has years of experience handling nursing home abuse and neglect cases and can assist you in determining if there is a claim related to preventable pressure ulcers. For a free consultation call 612-743-9048 or toll free at 1-888-452-6589 or fill out the form on this page to discuss your nursing home rights and your legal options. Email:


Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589
Free Consultation on Issues of Elder Abuse and Neglect Serving all of Minnesota Toll Free 1-888-452-6589