Transcript STAGING PRESSURE ULCERS

Part II
Selected Integumentary System
Diseases & Conditions
…More About Pressure
Ulcers & Staging…
STAGING PRESSURE ULCERS
 STAGE I Intact skin with non-blanchable redness. In pigmented skin,
color may be different (darker or lighter) than surrounding
skin.
http://www.lhsc.on.ca/wound/images/chart1.jpg
Source of photos in this presentation.
STAGING PRESSURE ULCERS
 STAGE II-
 Partial loss of dermis, a shallow open ulcer, May also be an
intact or open blister.
STAGING PRESSURE ULCERS….
 Stage III-Full thickness tissue loss. Subcutaneous fat may be
visible, but bone, tendon, and muscles are not.
 Further description: The depth of a stage III ulcer varies by
anatomical location.The bridge of the nose, occiput, and
malleolus do not have subcutaneous tissue, and stage III
ulcers can be shallow
Stage III
STAGING PRESSURE ULCERS
 Stage IV-Full thickness tissue loss with exposed bone,
tendon, or muscle. Slough or eschar may be present. Often
includes undermining or tunneling.
STAGING…..DTI
 The newest category for Pressure Ulcers is Deep Tissue Injury
(“DTI”)….
 Purple or maroon area of discolored intact skin or blood filled
blister due to damage of underlying soft tissue.
 May evolve to become covered with thick eschar. May rapidly
expose underlying layers, even with optimal treatment
STAGING…… “Unstageable”
 Full thickness tissue loss in which the base of the ulcer is
covered by slough and or eschar.
 Until enough slough or eschar is removed to expose the
base of the wound bed, the true depth and therefore the
stage cannot be determined.