- Stage 1 - non-blanching erythema of intact skin in light-skin. In darker skin, discoloration, edema or thickening may be present.
- Stage 2 - partial thickness injury involving epidermis, dermis or both. Clinically appears as an abrasion, blister or shallow ulcer.
- Stage 3 - full thickness skin injury with damage to subcutaneous tissue. May be down to but not through the fascia. Clinically appears as a deep crater. May have undermining.
- Stage 4 - full thickness skin injury with damage extending down to muscle, bone, tendon, and joint capsule. May also have undermining or sinus tracts.
Important points: It is difficult to detect stage 1 ulcers in darker-skinned individuals.
When eschar is present, the ulcer cannot be accurately staged.
Pressure ulcers under casts, braces, and support stockings can be easily missed. Those devices that can be easily removed for inspection of the skin should be removed on a regular basis. For casts, you must be alert to patient complaints of pain or clinical changes on exam of the extremity and remove the cast if necessary to inspect the skin1.
References:
- Bergstrom, N, Bennett MA, Carlson CE, et al. Clinical Practice guideline number 15: Treatment of pressure ulcers.
|
