Skin Integrity: Staging of Pressure Ulcers

Question 1

Stage I

Answer 1

Nonblanchable Redness (erythema) of Intact Skin;

Question 2

Stage I s/s

Answer 2

Discoloration, warmth,

edema, hardness, or pain.

Question 3

Stage II

Answer 3

Partial-thickness Skin Loss or Blister, loss of dermis

Question 4

Stage II s/s

Answer 4

shallow open ulcer with a
red-pink wound bed without slough. intact or open/ruptured filled blister. Shiny or dry shallow ulcer. no slough or bruising

Question 5

Stage III

Answer 5

Full thickness skin loss (fat visible)

Question 6

Stage III s/s

Answer 6

Subcutaneous fat may be visible;
but bone, tendon, or muscle is not exposed. Some slough may be
present. It may include undermining and tunneling

Question 7

Stage IV

Answer 7

Full thickness loss (muscle/bone visible)

Question 8

Stage IV s/s

Answer 8

exposed bone, tendon, or muscle. Slough or eschar may be present.
It often includes undermining and tunneling.

Question 9

Unstageable/Unclassified: Full-thickness Skin or Tissue

Loss—Depth Unknown

Answer 9

full-thickness
tissue loss in which actual depth of the ulcer is completely obscured
by slough (yellow, tan, gray, green, or brown) and/or eschar (tan,
brown, or black) in the wound bed

Question 10

Suspected Deep-Tissue Injury—Depth Unknown

Answer 10

purple or maroon localized area of
discolored intact skin or blood-filled blister caused by damage of
underlying soft tissue from pressure and/or shear