Four Stages of Pressure Ulcers
Stage 1
- Nonblanchable erythema of intact skin (when pressure applied to reddended area of skin its does not whiten)
- In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.
- In individuals with darker skin, colour changes may be more difficult to assess
- Skin remains intact
- changes in one or more of the following:
- skin temperature (warmth or coolness)
- tissue consistency (firm or boggy feel) and/or sensation (pain, itching).
The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
Stage 2
Partial thickness skin loss involving:
- epidermis
- dermis
- both dermis and epidermis
- The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage 3
- Full thickness skin loss involving damage to or necrosis (tissue death) of subcutaneous tissue that may extend down to, but not through, underlying fascia.
- The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage 4
- Full thickness skin loss with extensive destruction:
- tissue necrosis
- damage to muscle
- damage to bone
- or damage to supporting structures (e.g., tendon, joint capsule).
- Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers.
Stage 5
- extensive tissue necrosis (tissue death)
Pressure ulcers can be fatal. Infection in deep tissues and bone can be very difficult to treat. As always prevention is the best medcine.
Prevention:
- turning and repositioning patients every two hours to relieve force on pressure points.
- using pillows to support and cushion bony prominences such as elbows and heels.
Pressure points on the human body:
- pressure points are bony prominences on the body where pressure ulcers are likely to develop
Prone position (lying on stomach)
Supine position (lying on back)
Lateral postion (lying on side)
Sitting position
Perry, A, G, Potter, P, A, Ross-Kerr, J, C and Wood, M, J. 2006. Canadian fundamentals of nursing. 3rded. Toronto: Elselvier.
