Pressure Ulcers (bed sores)

Four Stages of Pressure Ulcers

pressure ulcer stages

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)

pressure_sores sites

Supine position (lying on back)

supine pressure_sores

Lateral postion (lying on side)

lateral pressure_sores

Sitting position

sitting pressure_sores04-e

Perry, A, G, Potter, P, A, Ross-Kerr, J, C and Wood, M, J. 2006. Canadian fundamentals of nursing. 3rded. Toronto: Elselvier.

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