Pressure Ulcers

Question 1

Stage 1

Answer 1

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Further Description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May indicate “at risk” persons. Stage I pressure ulcers may be difficult to detect in individuals with dark skin tones.

Question 2

Stage 2

Answer 2

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Stage II pressure ulcers may also present as an intact or open/ruptured serum-filled or serosangineous-filled blister.

Further Description:
Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal (incontinence associated) dermatitis, maceration or excoriation.

Question 3

Stage 3

Answer 3

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. Stage III pressure ulcers may include undermining and tunneling .

Further Description:
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 and 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.

Question 4

Stage 4

Answer 4

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. These ulcers often include undermining and tunneling .

Further Description:
The 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 and these ulcers can be shallow.

Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/tendon is visible or directly palpable.

Question 5

Unstageable

Answer 5

Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Further Description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and stage cannot be determined. However, it will be either a Stage III or IV.

Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Question 6

Suspected Deep Tissue Injury

Answer 6

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Question 7

Standard of care

Answer 7

Reposition every 2 hours
Position off ulcer site
Elevate HOB 30 degree as medically able
Specialty bed/chair /surface cushion per hospital
Consult wound care nurse

Question 8

Specific Treatment - Stage 1

Answer 8

Cleanse gently
Apply skin protection solution
Apply transparent or foam dressing
Change dressing every 3-5 days and PRN until redness resolves

Question 9

Specific Treatment - Stage 2

Answer 9

For intact blister
Cleanse site with saline
Apply skin protection solution around blister
Apply foam dressing
Change dressing every 3 days and PRN

For broken blister
Cleanse site with saline or wound cleanser
Apply skin protection solution around blister
Apply foam dressing or Hydrocolloid dressing
Change dressing every 3 days and PRN

Question 10

Specific Treatment - Stage 3

Answer 10

Minimal drainage and no tunnel or undermining
Cleanse site with saline or wound cleanser
Apply skin protection solution around wound
Apply foam dressing or Hydrocolloid dressing
Change dressing every 3 days and PRN

Deep Cavity
Cleanse as above
Pack moist saline gauze, pack lightly to base and undermined or tunnel areas
Apply skin protection solution around wound
Cover with dry dressing
Change dressing every 12 hours
If heavy drainage, can pack with Alginate and change dressing daily

Question 11

Specific Treatment - Stage 4

Answer 11

Treatment same as stage 3 Deep Cavity

Question 12

Unable to Stage

Answer 12

Dry necrotic (cleanse with wound cleanser and cover with gauze roll)
Wet necrotic (follow Stage 4 guidelines)

Question 13

Suspected Deep Tissue Injury

Answer 13

Cleanse intact skin, cover with Xeroform and secure with gauze roll
Apply foam dressing
Change dressing every 3 days and PRN