Pressure Ulcer Staging
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Staging Pressure Ulcers
- Stage I
Non-blanchable erythema of intact skin. Discoloration of skin. Skin is unbroken, but inflamed. May be painful. Warm to the touch. Condition is reversible. Prevent buildup of skin moisture where pressure exists. Prevent skin breakdown. Initiate an aggressive turning and pressure relief schedule.
- Stage II
Partial thickness breakdown in the skin involving partial loss of the epidermis and the dermis. Broken skin area is red and painful. Surrounding skin out from the ulcer area is reddened. Ulcer is superficial with a shallow crater and adjacent blister formation possible. Initiate an aggressive turning and pressure relief schedule to relieve pressure and prevent friction and shear forces. Cleanse the area with a wound spray. If the wound is creating exudate, place an alginate, hydrocolloid, foams or hydrofibers into the wound and cover with a biocclusive dressing. If the wound drainage is heavy, cover with gauze or ABD pads and secure with tape. If the wound is dry, hydrate the wound bed with a hydrogel. Place a petroleum impregnated gauze like Adaptic over the wound to prevent the hydrogel from easily coming out of the wound bed. Cover the wwound with gauze or a biocclusive. Change the dressing QD to BID. Control infection.
- Stage III
Full thickness skin loss. Necrosis of the underlying tissues may be present down to but not past the fascia. The necrotic tissue may be yellow or black in color. The ulcer will be painful. May be creating exudate. May be infected. Initiate an aggressive turning and pressure reduction program. Debride the area of all necrotic eschar. Control infection. Cleanse the wound with a wound cleanser. If exudate is present, dress the wound to control the exudate using alginates, hydrocolloids, foams or hydrofibers. Cover with a biocclusive if the drainage is less than moderate to severe. Otherwise cover with ABD pads to absorb the drainage. Change QD to BID depending on the amount of exudate. If by chance the pressure ulcer is dry, then hydrate the wound using hydrogels or hydrogel impregnated sheets to keep a moist wound environment.
Stage IV Full thickness skin loss accompanied by extensive lower layer tissue destruction of fascia, muscle. Destruction usually involves tissue loss down to the bones and joints. Necrosis and eschar formation will be extensive. Is painful. Initiate an aggressive turning and pressure reduction program. Control infection. Debride all necrotic tissue and eschar using sharp, blunt and enzymatic debridement techniques. Control exudate formation using products to control exudate (alginates, hydrocolloids, foams, hydrofibers). Cover with biocclusives or ABD pads where appropriate. Change the dressing QD to BID depending on the amount of exudate created.