- Used to describe the severity of pressure ulcers.
- Derived from previously published UK scales developed by a consensus panel of national tissue viability experts.
- This observational scale has 5 stages ranging from stage 0 to stage 4, where:
- 0 – No clinical evidence of a pressure sore.
- 1 – Discoloration of the intact skin.
- 2 – Partial-thickness skin loss or damage involving epidermis and/or dermis.
- 3 – Full-thickness skin loss involving damage or necrosis of subcutaneous tissue but not extending to underlying bone, tendon or joint capsule.
- 4 – Full-thickness skin loss with extensive destruction and tissue necrosis extending to bone, tendon or capsule.
- The scale has several variations, with the most common being the 1 and 2-digit scales, where the nature and severity of the ulcer are graded.
Clinical Considerations
- Observational pressure ulcer grading scales are open to bias and subjectivity resulting from individual interpretations. These interpretations reflect clinician knowledge and ability to identify anatomical structures and changes.
- The Stirling scale is easy to use, has good ulcer description, and good choice of descriptors. The descriptors in the 2-digit version enable a more accurate grading in comparison to other pressure ulcer severity scales. However, because the stage 1 descriptor of the scale focuses on skin discoloration, the validity of the Stirling scale is questionable when used with dark-skinned patients as this criteria may be masked by the skin pigment.
ICF Domain
Body Function ▶ Functions of the Skin
