Pressure Sore Evaluation
The evaluation of a decubitus ulcer includes a history and physical examination.
The diagnosis of decubitus ulcer is made during a physical exam. The stages of decubitus ulcer formation correspond to tissue layers.
Decubitus stage classification:
- Suspected Deep Tissue Injury: localized, purple or maroon area of intact skin, or a blood filled blister. This signifies damage to the underlying soft tissue.
- Stage I: intact skin with redness that does not blanch or disappear with finger pressure. The site is located over a boney prominence.
- Stage II: loss of the superficial skin surface, forming a shallow ulcer of pink or red tissue. This stage may also be represented by a blister, filled with clear fluid.
- Stage III: all of the skin layers are missing, leaving an ulcer that exposes underlying fat. The ulcer is not deep enough to expose underlying muscle or bone. The edges of the ulcer may separate from the deeper tissue layers.
- Stage IV: all of the skin layers and underlying fat are missing, leaving an ulcer that exposes muscle, tendons, or bone. The edges of the ulcer may separate from the muscle or bone.
- Unstageable: all of the skin layers are missing, but the ulcer is covered by yellow, tan, grey, green, brown, or black material, which makes it impossible to evaluate the stage. The stage becomes clear once the material is removed from the wound.
Tests that may be used to evaluate decubitus ulcer include:
Continue to Pressure Sore Treatment
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- Duimel-Peeters IG, Halfens RJ, Berger MP, Snoeckx LH. The effects of massage as a method to prevent pressure ulcers. A review of the literature. Ostomy Wound Manage. 2005 Apr;51(4):70-80. 
- Ratliff CR; WOCN. WOCN's evidence-based pressure ulcer guideline. Adv Skin Wound Care. 2005 May;18(4):204-8.