Ask the treatment expert: recognizing stage II and III pressure ulcers

Share this article:
Ask the treatment expert
Ask the treatment expert
Do you have any tips for recognizing Stage II pressure ulcers and how to determine when they become Stage III?

A Stage II pressure ulcer is partial thickness loss of the epidermis and dermis presenting as a shallow, open ulcer with a red/pink wound bed, without slough. A Stage II pressure ulcer also may present as an intact or open/ruptured serum-filled blister.

An easy way to remember this:

Stage II ulcers are pink, partial, and may be painful. If any yellow tissue (slough) is noted in the wound bed, no matter how minute, the ulcer cannot be a Stage II. Once there is visible slough in the wound bed, the ulcer is at least a Stage III or greater.

Detailed descriptions of pressure ulcer staging guidelines can be found at: www.npuap.org.

Our facility was recently given a deficiency for inappropriate treatment due to application of zinc oxide to a Stage II pressure ulcer on the buttocks. Why was this inappropriate?

Inappropriate use could include: allergy to zinc oxide, continued use of zinc oxide beyond seven days with no improvement in wound noted, and not following facility protocol—e.g., no policy or procedure in place for using zinc oxide on pressure ulcers. Appropriate use could include: superficial wound free from infection or wound with frequent exposure to moisture.
Share this article: