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