Pressure Ulcers : Types of ulcers stages/categories

Pressure Ulcers : Types of ulcers stages/categories 150 150 Tony Guo

Contributing factors

  • Amount of pressure (intensity)
  • Length of time pressure is exerted (duration)
  • Ability of tissue to tolerate externally applied pressure
  • Shearing force: Pressure exerted on skin when it adheres to bed and skin layers slide in direction of body movement
  • Moisture:  Excessive increases risk for skin breakdown

Types of ulcers stages/categories

Nonblanchable erythema

Intact skin with nonblanchable 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

Partial thickness

Loss of dermis

Shallow open ulcer with a red-pink wound bed, without slough (looks like a serosanguinous- filled blister)

Full-thickness skin loss

Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed

Include undermining and tunneling

Depth ulcer varies by location

Full-thickness tissue loss

Exposed bone, tendon, or muscle that are visible or directly palpable, and includes undermining and tunneling

Can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur

Other stages

Suspected deep tissue injury

Unknown depth

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

May be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.

Clinical manifestation

Signs

Leukocytosis

Fever

Increased ulcer size, odor, or drainage

Necrotic tissue

Indurated, warm, painful

Complications

Most common and keeps recurring

Cellulitis

Chronic infection

Osteomyelitis

Possible death

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