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Pressure Ulcers


Stage 1 Nonblanchable erythema of intact skin. Indication of beginning skin ulceration. Also- skin discoloration, warmth, edema, skin hardening
Stage 2 Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage 3 Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage 4 Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (for example, tendon or joint capsule)
Pressure: force between seated surface and body; happens from the inside out (from the bone outward)
Abrasion: skin is dragging, leads to more sores
Shearing: happens between the surface of skin and bony prominence; tissue is tearing (microtears in muscle fibers)
PUSH Tool 3.0 Observe and measure the ulcer. Categorize with respect to surface area, exudate, and type of wound tissue. Record a sub-score for each of these characteristics. Add the sub-scores to obtain total A comparison of total scores
Skin Assessment Tool Pressure Sore Data Collection Questionnaire Assess and record skin condition in relation to size, depth, and stage of sore in 29 assessment sites on body
Braden Scale Assesses risk in six areas sensory perception skin moisture activity mobility nutrition friction/shear
Created by: crystalfmulligan