Pressure Ulcer Staging

Question 1

Stages of Pressure Ulcer staging

Answer 1

Stage I-IV, Suspected Deep Tissue Injury, Unstageable

Question 2

Stage I

Answer 2

Intact skin with non-blanchable redness

Looks “discolored” compared to surrounding skin

Question 3

Stage II

Answer 3

Pratial-thickness tissue loss**
Dermis presents with shallow open ulcer with red/pink wound bed
May present as a blister or shhiny/dry shallow ulcer without slough/bruising

Question 4

Stage III

Answer 4

Full thickness tissue loss that exposes subcutaneous fat (NOT bone or tendon)
May include undermining and tunneling

Question 5

Stage IV

Answer 5

Full-thickness tissue loss with exposed bone, tendon or muscle (either visible or directly palpable)
Slough and eschar over part of wound bed
Undermining and tunneling
Can extend into muscle/supporting structures (fascia, joint capsule)

Question 6

Suspected Deep Tissue Injury

Answer 6

Purple or marroon localized area of intact skin or a blood-filled blister due to damage of underlying soft tissue
May evolve and become covered in eschar
Can evolve quickly and expose additonal layers of tissue even with optimal treatment

Question 7

Unstageable

Answer 7

Wound bed is completely covered by slough and/or eschar so depth is not apparent and therefore wound cannot be staged until removal

Question 8

Where should you not remove eschar?

Answer 8

The heel; it is the body’s “natural cover”