Pressure Injury Stages

Question 1

Pressure Injury stages

Answer 1

1: non-blanchable of intact skin
2: partial thickness skin loss with exposed dermis
3. Full thickness skin loss
4: Full thickness skin loss with tissue loss

Question 2

• Intact skin with a localized area of non-blanchable erythema.
• Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Answer 2

Stage 1: non-blanchable of intact skin

Question 3

• The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.
• Adipose (fat) is not visible and deeper tissues are not visible.
• Granulation tissue, slough and eschar are not present.
• These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.

Answer 3

Partial thickness skin loss with exposed dermis

Question 4

in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.
• Slough and/or eschar (dead tissues) may be visible.
• The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur.
• Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.

Answer 4

Full thickness skin loss

Question 5

with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.
• Epibole (rolled edges), undermining and/or tunneling often occur.
• Depth varies by anatomical location.

Answer 5

Full thickness skin loss and tissue loss