Pressure Ulcers

Question 1

Stage I

Answer 1

• Characterized by persistent redness
• Skin is intact with visible, non-blanchable redness over a localized area, typically a bony prominence
• Additional changes include alterations in skin temperature (warmth or coolness), tissue consistency (firm or soft), and sensation (pain, itching)
• Considered a PARTIAL thickness ulcer

Question 2

Stage II

Answer 2

• Involves the dermis with PARTIAL thickness loss which presents as a shallow open ulcer that can be shiny or dry
• Can also present as blister that is intact or open/ruptured
• The wound bed is a red pink color without slough or bruising

Question 3

Stage III

Answer 3

• Involves FULL-thickness tissue loss with subcutaneous fat possibly visible
• The depth of tissue loss is not obscured is slough (i.e., dead matter/necrotic tissue) is present
• Bone, tendon, or muscle is NOT exposed or directly palpable

Question 4

Stage IV

Answer 4

• Involves FULL-thickness tissue loss with bone, tendon, or muscle visible or directly palpable
• Osteomyelitis (serious bone infection) is also possible if ulcerextends into muscle, fascia, tendon, and/or the joint capsule

Question 5

Prevention

Answer 5

• Most effective intervention for pressure ulcers
• Can be achieved through: use of wheelchair cushions, flotation pads, and pressure-relief bed aids to distribute pressure over a larger skin surface
• Also through the training of the individual and/or caregivers in positioning, weight-shifting techniques, schedules, and proper skin care