Integumentary: Ulcers: Pressure: Staging

Question 1

Stage One

Answer 1

• Non-blanchable erythema of intact skin.

Question 2

Stage Two

Answer 2

• Partial thickness skin loss.
• Involves epidermis, dermis, or both
• Ulcer is superficial
• Presents as an abrasion, blister, shallow crater

Question 3

Stage Three

Answer 3

• Full thickness skin loss
• Involves damage to or necrosis of subcutaneous tissue
• Presents as deep crater

Question 4

Stage Four

Answer 4

• Full thickness skin loss
• Involves extensive destruction, tissue necrosis
• Damage to muscle
• Damage to bone
• Damage to supporting structures
• Possible undermining

Question 5

Unstageable

Answer 5

• Tissue depth os obscured due to slough or eschar and extent of damage can not be determined

Question 6

Deep Tissue Injury

Answer 6

• Discolored area of tissue that is not reversible and will likely progress to a full thickness injury.