NDNQI Pressure Ulcer Tutorial - Staging and Identification

Stage IV Pressure Ulcer

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

Further Description: The depth of a Stage IV 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.

Used with permission Lippincott Williams & Wilkins