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Integumentary
Pressure Ulcer Staging
| Clinical Finding | Stage |
|---|---|
| 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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