Redness, edema, superficial epidermis and dermis involved.
Redness, edema, blistering and hardening (induration) of tissue, skin is open and inflammation extends to the fat layer with superficial necrosis in advanced stage II lesions.
A full thickness skin lesion extending down to the muscle, the ulcer margin is thickened.
Ulcer extends down to the bone and includes bone destruction.
Prevention is the most effective intervention:
• Use wheelchair cushions, floatation pads, and pressure-relief bed aids to distribute pressure over a large skin surface.
• Train the individual and/or caregivers in positioning and weight-shifting techniques and schedules and in proper skin care.
1. Full push-ups, lateral leans, forward leans, or wheelchair tilt/recline options are common techniques used depending upon the abilities of the individual.
2. Weight shifts should occur every 30 min for 30 sec
Train in proper skin care
- keep skin free of excessive moisture, dryness, and heat
- check skin a least two timer per day for any evidence of breakdown.