Stages Flashcards
What are characteristics of an un-stage able pressure ulcer
Full thickness tissue loss I which the base of the ulcer is covered by slough and/or Escher in the wound bed
Unable to visualize true depth of tissue destruction
Stable ( dry intact without erythema or fluctuance) Escher on heels should not be removed, it serves as the body’s natural (biological) cover
What are characteristics of stage II pressure ulcer?
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough
Three P’s… Pink, Partial, Painful
Presence of slough indicates full thickness tissue damage
Slough is made up of dead collagen matrix from subcutaneous tissue
May present as an intact or open ruptured serum filled blister
Presents as a shiny or dry shallow ulcer without slough or bruising
NOT : used to describe tears, tape burns perineal dermatitis, maceration, or excoriation
What are characteristics of stage III pressure ulcer?
Full thickness tissue loss
Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed
Slough may be present but does not obscure the depth of tissue loss
May include undermining or tunneling
Depth varies by anatomical location, can be shallow on bridge of nose, ear, occiput, and malleolous. But may be quite deep in in areas of significant adiposity
Bone and tendon are not visible or directly palpable
What are characteristics of stage IV pressure ulcer?
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or Escher may be present. Some parts of the wound
Often include undermining or tunneling
Depth varies depending on location
Can e tend into muscle and or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible
Bone or tendon is visible or easily palpable
What are the characteristics of a Suspected deep tissue injury?
Purple or maroon localized area of disco.ore intact skin or blood filled blister due to damage of underlying soft tissue fro pressure or shear
Area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue…when documenting do not use “mushy”use soft… Boggy= wet, spongy, soft
May be dark tissue under fluid filled blister
What is back staging
Stage IV pressure ulcer can not be a Stage III, stage II, or stage I. Classify as stage IV healed. Same goes for the other stages, they can worsen, but never decrease is stage #. Always stage # healed
Mucosal pressure ulcer
Found on mucous membranes with a history of medical device in use at the location of the ulcer, not staged
Found on mucous membranes that line the tongue, GI tract, nasal passages, urinary tract and Vaginal canal, body cavities include most of the respiratory system, glans penis ( head of the penis) glans clitoris, urethra, inside of the foreskin and clitoral hood are mucous membranes not skin.
What is coagulum?
White shiny new growth on mucous membrane. Looks like slough
What are characteristics of stage I pressure ulcer?
Intact skin Non blanchable Redness of localized area Usually over bony prominence Painful, firm, soft, warmer, or cooler as compared to adjacent tissue May indicate "at risk" persons
