STAGING A PRESSURE ULCER

Definition Common Locations

Pressure ulcers are injuries to the skin and underlying Individuals who spend long periods of time in bed or seated in a
tissue caused by prolonged pressure, which restricts blood wheelchair are most at risk. Pressure ulcers most often affect the
flow. Pressure of bone tissue over bony parts of the body, such as those illustrated here:
against hard
surface Toes
Bone
Heels
Soft tissue Shoulder
blades
Blood Pinching off of Lower Spine Elbows Shoulder Back of
vessels blood vessels back bone blades the head Back bone

Skin Elbows
layers Friction of skin
against hard Lower back
Hard surface bone
surface
(bed) Ankle Knee Hip Shoulder Ear Heels Sitting bones

Staging Prevention
• Encourage or assist
with position changes,
Stage 1 Non-blanching erythema with intact epidermis at least every 1–2 hours.
• Avoid prolonged
moisture; protect skin
from urine, stool or
wound drainage
Partial-thickness ulcer, involving epidermis
Stage 2 if present.
and dermis
• Utilize specialized
mattresses, pads or
cushions to relieve and
Full-thickness ulcer extending through dermis redistribute pressure.
Stage 3
into subcutaneous tissue • Maintain tissue
integrity with a well
balanced, protein-rich
• Deep tissue destruction extending through diet.
Stage 4 fascia
• May involve muscle, bone, tendon CLINICAL TIP:
Always do a full
head-to-toe skin
• Depth of injury unknown due to presence assessment upon
Unstageable of necrotic tissue or eschar admission or transfer to
• Surgical debridement required for staging your unit, and document
appropriately.

NOTES

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