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Pressure Ulcers

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donna17's version from 2017-06-02 18:19

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Stage I (Closed) Intact skin with nonblanchable redness of localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, and warmer or cooler as compared to adjacent tissue. May be difficult to detect in individuals with darker skin tones.
Stage II (Open)Partial thickness loss of dermis presenting as a shallow, open ulcer with a red/pink wound bed, without slough. May also present as intact or open/ruptured serum-filled blister. Should NOT be used to describe skin tears, tape burns, maceration, or excoriation
Stage III Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is NOT exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III ulcers. Bone/tendon is not visible or directly palpable.
Stage IVFull-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Undermining and tunneling. depth varies by anatomical location. Stage IV ulcers can extend into muscle and/or supporting structures (fascia, tendons, or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Unstageable Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determines. Stable eschar on the heels serve as "the body's natural cover" and should not be removed.
Deep Tissue InjuryA bluish or purple localized area of discolored intact skin that may be described as a blood-filled blister. It is due to damage of underlying soft tissue from pressure or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, even with optimal treatment.
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