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Pressure Ulcer

NBCOT Study

QuestionAnswer
Stage 1 • no open wound or tears in the skin • skin reddens but does not blanch • warm to the touch • surrounding area may feel either firmer or softer • client may report pain
Stage 2 • partial-thickness skin loss • exposed dermis • open wound that looks like a scrape, blister, or tear • client reports pain and tenderness • warm to the touch • localized edema
Stage 3 • full-thickness skin loss • open wound that looks like a crater • wound extends into the fat layer but not to the tendon, muscle, or bone
Stage 4 • full-thickness tissue and skin loss • open wound with visible muscle, tendon, or bone • tunneling or undermining may both be present
Unstageable pressure ulcer Stage of pressure ulcer characterized by: • full-thickness skin and tissue loss • wound is completely covered by eschar or slough
Created by: crystalfmulligan