Staging Of Pressure Ulcers

Question 1

Nonblanchable erythema of intact skin. May include changes in skin temperature, tissue consistency, and/or sensation.

Answer 1

Stage I

Question 2

Partial-thickness skin loss: involves epidermis, dermis, or both. Ulcer is superficial, presents clinically as abrasion, blister, shallow crater

Answer 2

Stage II

Question 3

Full-thickness skin loss: involves damage or necrosis of subcutaneous tissue. May extend down to, but not through, underlying fascia. Presents clinically as deep crater.

Answer 3

Stage III

Question 4

Full-thickness skin loss: involves extensive destruction, tissue necrosis, or damage to muscle, bone, or supportive structures. Undermining and sinus tracts may be present.

Answer 4

Stage IV

Question 5

Tissue depth is obscured due to slough or eschar and extent of damage cannot be determined.

Answer 5

Unstageable

Question 6

Discolored area of tissue that is not reversible and will likely progress to full-thickness injury.

Answer 6

Deep tissue injury