Staging of Pressure Ulcers

                                         Suspected Deep Tissue Injury





When a pressure ulcer materializes it is graded based on he degree of tissue damage. The skin is made up of two respective layers which ae the epidermis and the dermis. The epidermis is the thin and tough outter layer of the skin. It contains no blood vessels and it can renew itself monthly. The dermis is the thick inner layer of the skin that is attached to the underlying tissue of the skin and provides the skin with strength and flexibility (Wound Care Information Network, n.d.).

The dermis layer of the skin consists of hair follicles. Its main function for the skin along with the hair follicles is to preserve fluid and electrolyte balance, protect from infections, sustain the body temperture,and to supply sensation (Wound Care Information Network, n.d.).

Stage I
In lighter toned people appears red and when pressed does not turn white. For darker toned people it may appear to be red, blue, or purple. This area of the skin can be painful, warm, and/or cooler than the surrounding skin.

Stage II
Is the partial thickness loss of the dermis. This outer layer of the skin will blister and/or form a shallow open area with the wound bed appearing to be red pink without slough. It can appeart to look like a blister.

StageIII
Is full thickness tissue loss. The tissue below is damaged with a sore that will look like a shallow crater. Subcutaneous tissue may be visible without seeing the bone, tendon, or muscle.

Stage IV
Appears with full thickness loss to the tissue. The crater is very deep. Deep enough to see bone, tendon, or muscle. Slough and eschar may also be visible.

Unstagable
Is full thickness tissue loss with the base of the ulcer covered with slough (yellow, tan, green, gray, or brown) or eschar that can appear to be black, tan , or brown. This stage of the pressure ulcer cannot be identified until the slough and/or eschar is removed.

Suspected Deep Tissue Injury
Is a localized area of the skin that is discolored and intact. It can appear as a blood filled blister related to the damage of the soft tissue underneath it from pressure and/or shearing.

References:

Wound Care Information Network (n.d.). Classifying or staging pressure ulcers. Retrieved from http://www.stoppain.org/pressureulcers/caregivers_staging.asp