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Stage IV Pressure Ulcer with UnderminingPressure ulcers or sores is one of the most sensitive indicators of proper nursing staffing.  Prevention requires excellent hygiene, bathing the patient daily and whenever the patient is soiled.  Padding of knees, legs, ankles, etc,. needs to be performed.  The patient should also be frequently turned or repositioned.  Every two hours is often necessary, unless special beds are used.  A pressure sore can start to form within two hours unless the patient is repositioned.      (click on picture to enlarge)

Pressure sores are categorized into four stages depending upon severity. Stage I is a sore with change in skin coloration, Stage II is a partial thickness of skin loss, a blister or abrasion, Stage III is full skin loss but not though underlining fascia, Stage IV has extensive damage to underlying muscles, bone, tendons and supporting tissue.   Read More

Patient Information on Bed Ulcer Prevention (JAMA)    PDF Version 

Stages of Pressure Ulcers/Sores

Stage I:  A sore with changes in skin coloration.  The skin is intact.

Stage II:  Partial thickness of skin loss.  Open shallow ulcer with a pink wound.

Stage III:  Full thickness of skin loss but not through to underlying fascia or bone.  Fat may be visible. 

Stage IV:  Exposing underlying fascia, muscles, bone and supportive tissue.  May have undermining or tunneling. 

In 2007, 257,412 Medicare patients developed Stage III or Stage IV pressure ulcers at a cost of over 11 billion dollars.1   

The above picture shows a Stage IV pressure ulcer which is down to fascia.  The ulcer extends beneath the skin and demonstrates undermining or tunneling.  Management Recommendations can be found at 

The Brandon Scale is often used to gauge a patient's risk of developing a bed sore or ulcer. A scale of 16 or lower in acute care and 18 or more in long-term care is indicative of a high risk for developing pressure sores and ulcers.

Definitions of the Stages of Pressure Ulcers, Predicting Risk of Development, Skin Assessment Tool, Turning Schedules and Prevention can be found at "Prevention Plug:  Home of the Brandon Scale", 


  1. CMS Fact Sheet Monday April 14th, 2008