ABCDE & Pressure Ulcers

A of ABCDE

Asymmetry

• One half of the mole or lesion looks different from the other half

B of ABCDE

Border Irregularity

• The borders are irregular, scalloped, or poorly defined.

C of ABCDE

Color variation

• The mole or lesion has multiple colors, such as brown, black, tan, red, white, blue, or pink.

D of ABCDE

Diameter

• >6 mm

E of ABCDE

Evolving

• changing in size, shape, color

Pressure Ulcers

• Causes: immobility, incontinence, poor nutrition, decreased sensation

• Prevention: reposition q2h, use pressure-relieving devices, maintain nutrition/hydration, and skin care

Stage 1

• Skin intact

• Red, non-blanchable area (does not turn white when pressed)

• May feel warm, firm, or painful

Stage 2

• Partial-thickness loss of skin

• Shallow open ulcer OR blister (intact or ruptured)

• Pink/red wound bed

Stage 3

• Full-thickness loss (damage through dermis into subcutaneous fat)

• Fat may be visible

• No exposed bone, tendon, or muscle

• May have slough (yellow tissue)

Stage 4

• Full-thickness loss with exposed bone, tendon, or muscle

• Often has slough or eschar (dead tissue)

• High risk of infection (osteomyelitis possible)

Unstageable

Full-thickness loss, but the wound base is covered by slough or eschar → can’t see how deep it is

ABCDE

Risk factors: fair skin, UV exposure, family history