Stages Of Pressure Ulcers Flashcards
What are the stages of pressure ulcers
-stage one
-stage two
-stage three
-stage four
-unstageable stage
What does a stage 1 pressure ulcer look like?
-skin will remain intact
-non-blanchable redness of a localized area
-common over bony prominences
-may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
-darkly pigmented skin may not have visible blanching, but color may differ from surrounding area.
What does a stage two pressure ulcer look like?
-the dermis is lost/not present
-shallow open ulcer with pink/red wound bed
-may also print as an intact or ruptured serum-filled blister
-can be shiny or dry shallow ulcer without slough or bruising
-adipose (fat) is NOT visible, and deeper tissues are NOT visible
-granulation tissue, slough, and eschar are NOT present
What does a stage three pressure ulcer look like?
-the dermis AND the epidermis are gone
-“FULL-THICKNESS” skin loss
-subcutaneous tissue may be visible, but bone, tendon, or muscle are NOT
-presents as deep crater with possible undermining or adjacent tissue
-ulcer depth varies by location, depending on depth of tissue in that area
what does a stage four ulcer look like?
-the internal anatomy is present & extends to the muscle
-“FULL-THICKNESS” loss, extends to muscle, bone, or supporting structures
-bone, tendon, or muscle may be visible or palpable
-slough or eschar may be present on some parts of the wound bed
-undermining and tunneling may also occur
-WHEN TESTING; USE STERILE PROCEDURES (qTip)
What does an unstageable ulcers look like?
-eschar and slough are completely covering the entire wound
-“FULL-THICKNESS” tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
-slough may be yellow, tan, green, grey, or brown
-eschar may be tan, brown, or black in the wound bed
-slough or eschar must be removed to expose the bas of the wound in order to stage
*STABLE, DRY ESCHAR ON HEELS SHOULD NOT BE REMOVED
