Pressure injuries/ulcers with skin intact

Staging a pressure injury/ulcer can be challenging for even the most experience clinician. The next few posts will give guidelines and examples of different depth pressure ulcers, along with treatment guidelines for each category.
Pressure injuries/ulcers with skin intact


According to the NCUAP guidelines, the pressure injury in the attached photo would be staged as:

  • Unstageable
  • Suspected deep tissue injury
  • Stage 1
  • Stage 2

Answer: C

The NPUAP guidelines define a Stage 1 pressure injury as the following:

Non-blanchable erythema of intact skin.  Intact skin with a localized area of non-blanchable 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; these may indicate deep tissue pressure injury.[1] 

The skin in the attached photograph has signs of pressure injury besides the areas that are non-blanchable (meaning that pressing one’s finger on the area does not force blood out of the capillaries and make the skin paler or white).  There is a change in the surrounding skin texture that is termed peau d’orange, or skin of an orange, which may be observed before the change in color.  Another sign is the dry flaky appearance of the skin, indicating decreased sub-epidermal moisture, which has been shown to predict early skin pressure damage as much as one week prior to color changes.[2]

The emaciated appearance of the patient’s physique is an indication of high risk for pressure injury. A decrease in body mass of 20-30% results in an increased risk for pressure injury and impaired or delayed wound healing.  Therefore, treatment of any patient who is at risk for or has a pressure injury/ulcer includes a nutritional assessment for malnutrition which includes the following six characteristics:

  • Insufficient energy intake
  • Weight loss
  • Loss of muscle mass
  • Loss of subcutaneous fat
  • Localized or generalized fluid accumulation that may sometimes mask weight loss
  • Diminished functional status as measured by hand-grip strength[3]

Treatment of Stage 1 pressure injuries includes removal of any source of pressure by frequent repositioning and use of pillows, foams, etc. to off-load the affected area; adequate hydration; and adequate nutrition, which for a malnourished patient is 50% above normal (normal is defined as 20-25 kcal/kg/day or 0.8 grams of protein/kg/day).  In addition, covering the affected area with a protective dressing (e.g. silicone-backed foam) to decrease the risk of friction may be helpful in preventing further skin damage.  Twice daily or every shift observation to monitor for injury progression is also advised as part of the treatment plan for Stage 1 pressure injuries.

[1] National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.  Available at

[2] Kim C, Park S, Ko JW, Jo S.  The relationship of sub-epidermal moisture and early stage pressure injury by visual skin assessment.  Journal of Tissue Viability.  2018;27(3):130-134.

[3] Collins N, Friedrich L. Appropriately diagnosing malnutrition to improve wound healing.  Wound Clinic.  2016;10(11):10-12.


Further information on diagnosing and treating pressure injuries/ulcers may be found at the following site:


Garcia AD, Sprigle S. Pressure injuries and ulcers. In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition.  New York: McGraw Hill Education.  2019, 171-198.  Available at


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