Pressure Ulcer Staging Flashcards
(6 cards)
1
Q
Stage 1
A
Intact skin with non-blanchable redness
May feel painful, firm, soft, warmer or cooler than surrounding skin
Harder to detect on darker skin tones
2
Q
Stage 2
A
Partial-thickness skin loss (top layer broken)
No slough or bruising
May look like a ruptured blister
3
Q
Stage 3
A
Full-thickness tissue loss
No bone, tendon, or muscle visible
May have slough and depth
4
Q
Stage 4
A
Full-thickness tissue loss with exposed bone, tendon, or muscle
Eschar or slough may be present
5
Q
Unstageable/Unclassified
A
Wound bed covered by eschar or slough → depth cannot be determined
6
Q
Suspected Deep Tissue Injury
A
Intact skin
Looks like a bruise (purple or maroon), may feel firm or boggy
