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Pressure Injuries
Stages Of pressure Injuries
Question | Answer |
---|---|
Describe Stage 1 pressure injury | Skin is red, nonblanchable |
Describe Stage 2 pressure injury | Top layer is broken, open, shallow ulcers, red or pink moisture on the wound |
Describe Stage 3 pressure injury | A deep wound that extends beyond the epidermis and dermis (no structures shows yet, no bones or ligaments) |
Describe Stage 4 pressure injury | exposed bone and underlining body structures (extremely painful; has an awful odor unless it has been surgically removed). Small amount of sloth and eschar present |
Describe Unstageable pressure injury | has eschar and sloth covering the rest of the injury |
Describe Deep Tissue injury | Skin is intact, have a dark purple/maroon area that is nonblanchable |
Nonblanchable vs Blanchable | - Blanchable: Touch the redden area and there is a white spot revealed - nonblanchable: Touch the redden area and there is still a red spot |
What is Escar? | black, dead tissue; can’t stage because you have no idea what’s underneath it |
What is Sloth? | whiteish, yellowish, grayish, dead tissue that covers the bed of the wound; can’t stage because you don’t know what’s underneath it |