Stage I Pressure Ulcers

Change in color, consistency, or temperature

of the skin. Possibly only detected by tactile
exam.
Skin is intact and the underlying tissues are
unaffected.
Warning sign: Intereventions are preventative
of future skin issues.

Stage IV Pressure Ulcers

Extend into the subcutaneous tissue with
involvement of bone, muscle, and fascia

Stage II Pressure Ulcers

Involvement of epidermal layer of skin, and
may extend to dermis
May appear as shallow, open areas or intact
serum-filled or serosanguineous blisters.
Break of skin integrity
Often requires serous drainage and localized
dermatologic issues

Unstageable Pressure Ulcers

If unable to visualize bottom of ulcer due to
covering by thick necrotic tissue or scabbing,
staging is not possible
Only can stage with debridement

Stage III Pressure Ulcers

Extend into the subcutaneous tissue but there
is no involvement of bone, muscle, and fascia
(may be visible)
If Stage II in appearance but with necrotic
slough in the ulcer
May involve tunneling and undermining

Unstageable Pressure Ulcers

Surface appears as Stage I or II pressure ulcer,
but there is severe damage to underlying tissues
is severe, with possible internal necrosis.
Most common at interface between bone and
soft tissue
Surface skin can quickly advance to stage II or
IV
High suspicion with large ulcers and low braden
scores

Pressure ulcer (Bedsore; Decubitus ulcer)

Measure Braden Scale (1-4 for each criteria; lower

scorer=worse)
o Sensory Perception- Ability to process/
communicate input from skin
o Moisture-Exposure to moisture
o Activity- Level of activity (irrespective of mobility)
o Mobility- Ability to change/control body position

o Nutrition- Usual pattern/amount of caloric intake

o Friction and Sheer- How they move within confines
Treatment
o Eliminate external pressure while maintaining local
tissue integrity
o Facilitate natural healing while removing necrotic
tissue

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Adequate pain relief

Reducing Bacterial load

Treating underlying condition