Only $35.99/year

Terms in this set (110)

-stage I - Intact skin with no redness of a localized area, usually over a bony prominence.; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared with adjacent tissue. Stage I may be difficult to detect in people with dark skin. May indicate "at risk" people (a heralding sign of risk).
-Stage II - Partial-thickness loss of dermis presenting as a shallow open ulcer with a reddish pink wound bed, without slough (pus). May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (indicates suspected deep tissue injury). This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
- Stage III - Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Stage IV - Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue so these ulcers may be shallow. Stage IV ulcers can extend into muscle, supporting structures (e.g., fascia, tendon, joint capsule), or both, making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable