How deep is the wound?

• Wound depth cannot be accurately assessed until cleaned of slough, debris, and dressing residue.
  
  
• Wounds that are covered with eschar cannot be assessed for depth.
  
  Staging Pressure Ulcers
  
  

  Stage 1	Stage 2	Stage 3	Stage 4	Unstageable (X)
  An observable area of intact skin that has persistent redness as a result of pressure.	An ulcer that involves the epidermis and may extend to the dermis. May appear as a blister, crater, or abrasion.	An ulcer that involves the subcutaneous tissue layer and may extend to but not through the fascia. May appear as a crater and can have undermining.	An ulcer that extends through the fascia and can involve muscle, bone,tendons, and other supporting structures. Undermining and tunneling can be present.	An ulcer where the wound bed cannot be visualized due to slough or eschar. This tissue needs to be removed before staging can take place.

  
  
  
• "Wounds with depth are packed to eliminate dead space and the potential for abscess formation. However, over-packing a wound can result in ischemia of fragile tissue"
  
  
• Packing should be loose, while contacting all wound surfaces and not mounding above the skin surface
  
  
• Wounds should be thoroughly assessed for undermining, tunneling and the depth of these should be measured with a sterile cotton swab
  
  
• Accurate measuring and recording of wound depth is essential in evaluating wound healing