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Ungradable

Sylvie Hampton
Tissue Viability Nurse Specialist
Figure 1. Is this a blister with a deep tissue injury? Or is it a category 2 with a blister ‘roof’ that has become leathery?
Figure 2. This is possibly going to be a Category 4 but we cannot see or feel that for certain
Figure 3. There is a possibility this is a Category 2. If it was a blister which has a roof that has hardened, it is possible this roof will demarcate revealing healed tissue. OR it could be Category 3 or 4.
Figure 4. This is quite possibly a deep tissue injury, given the inflammation surrounding the necrotic area. However, we cannot be sure.
Figure 5. Category 3 or 4? Unable to tell at this point.

If a wound bed cannot be seen due to dead tissue or slough, it should be reported as ‘ungradable’. The reason for this is that it is impossible to see if bone is exposed or whether it is a simple blister that has turned black on the surface but is still a healing category 2 under the blister roof. 

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