How do you determine the stage of a pressure ulcer?

Stages of Pressure Injuries

Table of Contents

Stage 1 sores are not open wounds.
At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful.
During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater.

How do you document a Stage 1 pressure ulcer?

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.

What are the 4 categories of pressure ulcers?

Category I – non-blanchable erythema. Category II – partial thickness skin loss. Category III – full thickness skin loss. Category IV – full thickness tissue loss.

What are the four stages categories used to classify pressure ulcers?

Classifications of Pressure Ulcers.

Stage I.

Intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Stage II.

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Stage III.

Full thickness tissue loss.

Stage IV.

What are the limitations or restrictions of staging pressure ulcers?

Recently, clinicians have drawn attention to numerous limitations associated with the current staging system, including the inability to differentiate between an inflammatory response involving intact skin and a deep tissue injury (deep bruising) underneath intact skin.

How do you treat a Stage 3 pressure ulcer?

Treatment of Stage 3 Bedsores

Relieving pressure: Taking pressure off the affected area helps ensure it will not worsen.
Debridement: Doctors remove the eschar and slough from the sore.
Cleaning: Once the bedsore is free of eschar and slough, water or saltwater will be used to clean it.

How would you describe Stage 3 pressure ulcer?

Stage 3. These sores have gone through the second layer of skin into the fat tissue. Symptoms: The sore looks like a crater and may have a bad odor. It may show signs of infection: red edges, pus, odor, heat, and/or drainage.

What is Stage 3 pressure injury?

Stage 3 bedsores (also known as stage 3 pressure sores, pressure injuries, or decubitus ulcers) are deep and painful wounds in the skin. They are the third of four bedsore stages. These sores develop when a stage 2 bedsore penetrates past the top layers of skin but has yet not reached muscle or bone.