Skin Integrity: Staging of Pressure Ulcers Flashcards Preview

Exam 3 > Skin Integrity: Staging of Pressure Ulcers > Flashcards

Flashcards in Skin Integrity: Staging of Pressure Ulcers Deck (10)
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1

Stage I

Nonblanchable Redness (erythema) of Intact Skin;

2

Stage I s/s

Discoloration, warmth,
edema, hardness, or pain.

3

Stage II

Partial-thickness Skin Loss or Blister, loss of dermis

4

Stage II s/s

shallow open ulcer with a
red-pink wound bed without slough. intact or open/ruptured filled blister. Shiny or dry shallow ulcer. no slough or bruising

5

Stage III

Full thickness skin loss (fat visible)

6

Stage III s/s

Subcutaneous fat may be visible;
but bone, tendon, or muscle is not exposed. Some slough may be
present. It may include undermining and tunneling

7

Stage IV

Full thickness loss (muscle/bone visible)

8

Stage IV s/s

exposed bone, tendon, or muscle. Slough or eschar may be present.
It often includes undermining and tunneling.

9

Unstageable/Unclassified: Full-thickness Skin or Tissue
Loss—Depth Unknown

full-thickness
tissue loss in which actual depth of the ulcer is completely obscured
by slough (yellow, tan, gray, green, or brown) and/or eschar (tan,
brown, or black) in the wound bed

10

Suspected Deep-Tissue Injury—Depth Unknown

purple or maroon localized area of
discolored intact skin or blood-filled blister caused by damage of
underlying soft tissue from pressure and/or shear