Selected Integumentary System Diseases & Conditions The SKIN… Part II Selected Integumentary System Diseases & Conditions …More About Pressure Ulcers & Staging…

STAGING PRESSURE ULCERS STAGE I- Intact skin with non-blanchable redness. In pigmented skin, color may be different (darker or lighter) than surrounding skin. http://www.lhsc.on.ca/wound/images/chart1.jpg Source of photos in this presentation.

STAGING PRESSURE ULCERS STAGE II- Partial loss of dermis, a shallow open ulcer, May also be an intact or open blister.

STAGING PRESSURE ULCERS…. Stage III-Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscles are not. Further description: The depth of a stage III ulcer varies by anatomical location.The bridge of the nose, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow

Stage III

STAGING PRESSURE ULCERS Stage IV-Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining or tunneling.

STAGING…..DTI The newest category for Pressure Ulcers is Deep Tissue Injury (“DTI”)…. Purple or maroon area of discolored intact skin or blood filled blister due to damage of underlying soft tissue. May evolve to become covered with thick eschar. May rapidly expose underlying layers, even with optimal treatment

STAGING…… “Unstageable” Full thickness tissue loss in which the base of the ulcer is covered by slough and or eschar. Until enough slough or eschar is removed to expose the base of the wound bed, the true depth and therefore the stage cannot be determined.