Pressure Ulcer Classification

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  • Topic: Dermis, Subcutaneous tissue, Cancer staging
  • Pages : 1 (257 words )
  • Download(s) : 21
  • Published : April 6, 2013
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PRESSURE ULCER CLASSIFICATION
Category/ Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones1.

Category/ Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister1.

Category/ Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss1.

Category/ Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunnelling. Category/Stage IV ulcers can extend into muscle and/ or supporting structures (e.g., fascia, tendon or joint capsule)1. 1. This extract has been taken from the Pressure Ulcer Prevention and Treatment EPUAP Review Guideline written by the European Pressure Ulcer Advisory Panel (2009). This poster is designed as a guide only and Invacare strongly recommend the full EPUAP guidelines are studied. Invacare accept no responsibility for medical intervention as a result of misinterpretation of the content of this poster.

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