Flashcards in Skin Integrity: Staging of Pressure Ulcers Deck (10)
Nonblanchable Redness (erythema) of Intact Skin;
Stage I s/s
edema, hardness, or pain.
Partial-thickness Skin Loss or Blister, loss of dermis
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
Full thickness skin loss (fat visible)
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
Full thickness loss (muscle/bone visible)
Stage IV s/s
exposed bone, tendon, or muscle. Slough or eschar may be present.
It often includes undermining and tunneling.
Unstageable/Unclassified: Full-thickness Skin or Tissue
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