Wound Classification Systems

Wound Care Classification Systems

A. Staging of Pressure Ulcers

(Staging is only used for Pressure Olcers)

Stage I: Redness only

Stage I
 

Stage II:

Loss of epidermis and partial loss of dermis not extending into subcutaneous tissue

Stage IIa
Stage IIb
Partial thickness skin loss of the dermis

Stage III:  

Full thickness wound. Includes loss of epidermis and dermis. Extends into subcutaneous tissue.

Stage IV:  

Deep penetrating wound. Includes loss of epidermis, dermis and subcutaneous tissue. Extends into muscle and/or bone.

Stage III
Stage IV

B. Appearance

  1. Red wounds (granulating wound beds)
    • acute: frank bleeding or recent homeostasis
    • chronic: clean pink to bright or dark red granulation tissue
  2. Yellow wounds
    Yellow slough or eschar
    • Soft necrotic tissue or thick tenacious exudate ranging in color from creamy ivory to yellow green.
    • Autolytic cellular debris may be present
  3. Black wounds
    Necrotic wound
    • Black, gray or brown adherent necrotic tissue (eschar).
    • Autolytic cellular debris may be present.