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Stages of Pressure Ulcers

Unstagable Ulcer

Index

Braden Risk Assessment Scale

Stage 1

Stage 2

Stage 3

Stage 4

(citation for table) Braden BI, Bergstom N. Clinical Utility of the Braden Scale for Predicting Pressure Sore Risk, Decubitus August 1989, 2; 44 -51.

Total Braden Score _____________15-16 Mild Risk 12 -14 Moderate Risk < High risk 15 -18 is considered Mild Misk for those > 75 years

Early detection. Pressure Ulcers. (n.d.). https://pressureulcerprevention.weebly.com/early-detection.html

Braden Risk Assessment Scale

Bachelor's/Master's Thesis Title
Author: Name and surname

Early detection. Pressure Ulcers. (n.d.). https://pressureulcerprevention.weebly.com/early-detection.html

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching (turns white when pressed on); its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk persons".

Stage 1

Early detection. Pressure Ulcers. (n.d.). https://pressureulcerprevention.weebly.com/early-detection.html

Partial-thickness loss of dermis manifesting as a shallow open ulcer with a red-pink wound bed, without slough (dead tissue layer). May also manifest as an intact or open/ruptured serum-filled blister. Manifests as a shiny or dry, shallow ulcer without slough or bruising (indicates suspected deep tissue injury). This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Stage 2

Early detection. Pressure Ulcers. (n.d.). https://pressureulcerprevention.weebly.com/early-detection.html

Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon and muscle are not exposed. Slough may be present, but does not obscure depth of tissue loss. May include undermining and tunneling. Depth of a stage III pressure ulcer varies by location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant fat composition can develop extremely deep stage II pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage 3

Early detection. Pressure Ulcers. (n.d.). https://pressureulcerprevention.weebly.com/early-detection.html

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (formed scab) may be present on some parts of the wound bed. Often include undermining or tunneling. Depth of a stage IV ulcer varies by location. Again, bridge of the nose, ear, occiput and malleolus (bone of the heel) do not have underlying tissue and they can be shallow. Stage IV ulcers can extend to muscle and/or supporting structures (i.e., fascia, tendon, joint capsule) making osteomyelitis (bone disease) possible. Exposed bone/tendon is visible or directly palpable.

Stage 4

Early detection. Pressure Ulcers. (n.d.). https://pressureulcerprevention.weebly.com/early-detection.html

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biologic) cover" and should not be removed.

Unstageable Ulcer