Classification of Pressure Ulcers Flashcards

Study Notes

Classification of Pressure Ulcers

Stage I: Nonblanchable Redness of Intact Skin
- Characterized by nonblanchable erythema over a localized area, often over bony prominences.
- Possible signs include skin discoloration, warmth, edema, hardness, or pain.
- Detection may be challenging in individuals with darkly pigmented skin.
- Indicates individuals may be "at risk" for developing pressure ulcers.
Stage II: Partial-thickness Skin Loss or Blister
- Appears as a shallow open ulcer with a red-pink wound bed, without sloughing.
- May present as an intact or ruptured serum-filled blister.
- Ulcer surface can be shiny or dry, and should not involve skin tears or burns.
- Bruising or slough should not be present in this stage.
Stage III: Full-thickness Skin Loss (Fat Visible)
- Involves full-thickness tissue loss where subcutaneous fat may be visible.
- Bone, tendon, or muscle are not exposed; slough may be present.
- May include undermining and tunneling, depth can vary by location.
- Areas like the bridge of the nose and ears may have shallow ulcers due to lack of subcutaneous tissue.
Stage IV: Full-thickness Tissue Loss (Muscle/Bone Visible)
- Full-thickness tissue loss with exposed bone, tendon, or muscle.
- Presence of slough or eschar, often accompanied by undermining and tunneling.
- Can extend into muscle or supporting structures; exposed bone/muscle is palpable.
- Depth can vary significantly depending on the location.
Unstageable/Unclassified: Full-thickness or Tissue Loss - Depth Unknown
- Defined by an ulcer where the base cannot be visualized due to obscuring slough or eschar.
- Full-thickness tissue loss with depth assessment hindered until enough material is removed.
- Wound may contain slough in colors like yellow, tan, gray, green, or brown, and eschar may appear tan, brown, or black.
Suspected Deep-Tissue Injury - Depth Unknown
- Indicates a purple or maroon area of discolored intact skin or blood-filled blister.
- Results from damage to underlying soft tissue due to pressure/shear forces.
- Signs may include pain, firmness, or temperature variation compared to adjacent tissue.
- May evolve to expose underlying layers of tissue rapidly, with thin eschar potentially covering the area.

Description

This quiz consists of flashcards that focus on the classification of pressure ulcers, specifically detailing various stages and their definitions. You will learn the characteristics of each stage, including Stage I, which features nonblanchable redness of intact skin. Ideal for healthcare professionals or students studying patient care.