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Integumentary

Pressure Ulcer Staging

Clinical FindingStage
Intact skin w/ non-blanchable redness of a localized area usually over a bony prominence Stage I
Painful, firm, soft, warmer or cooler as compared to adjacent tissue Stage I
Difficult to detect in individuals w/ dark skin tones Stage I
Darkly pigmented skin presents as local coloration differing from the surrounding area. Stage I
Partial-thickness loss of the dermis presenting as a shallow open ulcer w/ a red or pink wound bed. Stage II
Intact or ruptured serum-filled blister or presents as a shiny or dry shallow ulcer w/o slough or bruising Stage II
Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation Stage II
Full-thickness tissue loss Stage III
Subcutaneous fat may be visible but bone, tendon or muscle are not exposed Stage III
Slough may be present, but does not obscure the depth of tissue loss` Stage III
May include undermining and tunneling Stage III
Bone and tendon are not visible or directly palpable Stage III
Full-thickness tissue loss w/ exposed bone, tendon, or muscle that is visible or directly palpable Stage IV
Slough or eschar may be present Stage IV
Undermining and tunneling may be present Stage IV
Can extend into muscle and supporting structures (e.g., fascia, tendon, joint capsule) making osteomyelitis possible Stage IV
Created by: glopez111
 

 



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