skin, hair, nails assessment

1

1

2

2

3

3

4

4

Braden Scale Factors

nutrition, sensory perception, moisture, friction and shear, mobility, activity, mobility

Stage 1

skin is intact, skin is nonblancable, persistent redness

Stage 2

a partial thickness wound, involves the epidermis, intact or ruptured blisters

Stage 3

Full thickness wound, does not extent to muscle or bone, 

Stage 4

extends into mucles, bone, and connective tissue. RISK of osteomylitis

unstageable pressure injury

full thinkness would with too much necrotic tissue or eschar, that makes it impossible to stage, cannot stage until debridement and cleaned

deep tissue injury

area of purple/ maroon or a blood-filled blister

true or false: the stage of pressure injury changes as it heals

false - we say healing stage 3 or healed stage 4