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Pressure Ulcers
Rehabilitation
| Term | Definition |
|---|---|
| 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