Lecture 5: Stages of Pressure Injuries

What are the 6 Stages of Pressure Injuries?

• Deep Tissue Injury

• Unstageable

• Stage 1

• Stage 2

• Stage 3

• Stage 4

Deep Tissue Injury:

• What is it?

• What often precedes skin color changes?

• Results from:

• Persistent, NON-Blanchable; Deep Red, Maroon, or Purple Discoloration, or Blood Blister

• Pain and Temp often precedes skin color changes

• Results from:

  • Intense and/or prolonged tissue pressure and shear foces at the bone-muscle interface

Deep Tissue Injury:

• The wound may rapidly evolve to reveal what?

• If necrotic tissue is present, structures what can be visible?

  • What does this indicate?

• Reveal the actual extent of tissue injury OR may resolve w/o tissue loss.

• Necrotic Tissue = Subcutaneous Tissue, Granulation Tissue, Fascia, Muscle, or Other Underlying Structures are visible

  • Indicates FULL thickness tear (Unstageable, Stage 3 or Stage 4)

Unstageable:

• What is it?

• Can extent of tissue damage within the ulcer be confirmed?

  • Why or Why Not?

• If Slough or Eschar is removed, what will be revealed?

• Obscured full thickness skin and tissue loss

• NOOOOO

  • Because obscured by Slough or Eschar

• Revealed Stage 3 or 4 Pressure Ulcer

Unstageable:

• Describe Stable Eschar:

• Stable Eschar on the HEEL or ISCHEMIC LIMB should not be what?

• Stable Eschar: Dry, adherent, intact without erythema or fluctuance

• Should NOT be removed or softened

Stage 1:

• What is it?

• Stage 1 has the presence of what 2 things that may preceded visual changes?

• Color changes do NOT include what 2 color discolorations?

  • These 2 color dislocations may indicate what Pressure Wound?

• Non-Blanchable erythema of intact skin

• Presence of:

  • Blanchable Erythema

  • Changes in Sensation, Temp, Firmness

• Purple or Maroon

  • Deep Tissue Injury

Stage 2:

• What is it?

• Describe the wound bed:

• The wound bed may also present as what?

• What is NOT visible/present?

• Partial thickness skin loss w exposed dermis

• Wound Bed:

  • Viable, pink or red, moist

• Present as an intact or ruptured serum filled blister

• Not:

  • Adipose (Fat) and Deeper Tissue

  • Granulation Tissue

  • Slough

  • Eschar

Stage 2:

• Stage 2 Wounds are commonly a result from what where in the body?

• Stage 2 Wounds should NOT be used to describe what other type of wound and its subtypes?

• Commonly result from:

  • Adverse microclimate and shear in the skin

  • Over pelvis and heel

• NOT be used to describe:

  • Moisture Associated Skin Damage (MASD)

    • Incontinence Associated Dermatitis (IAD)

    • Intertriginous Dermatitis (ITD)

    • Medical Adhesive Related Skin Injury (MARSI)

    • Traumatic Wounds (Skin Tears, Burns, Abrasions)

Stage 3:

• What is it?

• What type of tissue is visible?

• What is present within the wound base?

• What type of wound edge is present?

• Full thickness skin loss

• Adipose Tissue is visible

• Wound Base:

  • Granulation Tissue

  • Sough and/or Eschar

• Wound Edge:

  • Epibole

  • Undermining and Tunneling may occur

Stage 3:

• Depth of tissue damage varies by what?

• Areas of significant ______ can develop what?

• What structures are NOT exposed?

• Is Slough or Eschar obscures the extent of tissue loss, what type of stage is it?

• Depends on Anatomical Location

• Adiposity; Deep Wounds

• NOT:

  • Fascia

  • Muscle

  • Tendon

  • Ligament

  • Cartilage

  • Bone

• Unstageable Pressure Ulcer

Stage 4:

• What is it?

• What is may be visible in their wound base?

• What type of wound edges often occur?

• Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer

• Wound Base: Slough and/or Eschar

• Wound Edges:

  • Epibole

  • Undermining and/or Tunneling

Stage 4:

• Depth varies by what?

• If slough or eschar obscures the extent of tissue loss, this is what stage of wound?

• Anatomical location

• Unstageable Pressure Ulcer