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Pressure Ulcer Staging

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bjtmeyer's version from 2016-09-13 15:14

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Question Answer
Stage IIntact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching, but instead present a local coloration differing from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.
Stage IIPartial-thickness tissue loss of the dermis presenting as a shallow open ulcerwith a red or pink wound bed.
Stage IIIFull-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present, but not obscure the depth of tissue loss. Undermining and tunneling possible. Bone and tendon are not visible or directly palpable.
Stage IVFull-thickness tissue loss with exposed bone, tendon or muscle that is visible or directly palpable.
UnstagableFull-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. Slough and/or eschar will need to be removed before the true depth and stage can be determined.
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