Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most effective wound treatment. Unstageable pressure injuries have full- thickness skin loss with slough and/or eschar, which prevents visualization of the wound base. Slough in a wound base appears as yellow or tan stringy tissue; eschar is dried, black or brown necrotic tissue. The wound cannot be staged until slough and eschar are debrided by a wound care nurse or health care provider and the base can be visualized
(Option 4).
(Option 1) Stage 2 pressure Injuries present as shallow, open wounds with partial- thickness skin loss of the dermis. The wound bed is red or pink, and may be shiny or dry.
(Option 2) Stage 3 pressure injuries have full-thickness skin loss. Subcutaneous fat may be observed; however, underlying tendon, muscle, or bone is not visible. The wound bed may tunnel or extend under the edge of surrounding skin, as a lip or pocket (undermining).
(Option 3) A deep-tissue injury presents as an area of dark purple or maroon discolored, intact skin, which is caused by a pressure or shearing injury to underlying tissue.
Educational objective:
Unstageable pressure injuries have full-thickness skin loss with slough and/or eschar in the base that prevents the nurse from fully visualizing the wound depth to determine the stage. Slough and eschar must be debrided before the wound can be staged.
Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most effective wound treatment. Unstageable pressure injuries have full- thickness skin loss with slough and/or eschar, which prevents visualization of the wound base. Slough in a wound base appears as yellow or tan stringy tissue; eschar is dried, black or brown necrotic tissue. The wound cannot be staged until slough and eschar are debrided by a wound care nurse or health care provider and the base can be visualized
(Option 4).
(Option 1) Stage 2 pressure Injuries present as shallow, open wounds with partial- thickness skin loss of the dermis. The wound bed is red or pink, and may be shiny or dry.
(Option 2) Stage 3 pressure injuries have full-thickness skin loss. Subcutaneous fat may be observed; however, underlying tendon, muscle, or bone is not visible. The wound bed may tunnel or extend under the edge of surrounding skin, as a lip or pocket (undermining).
(Option 3) A deep-tissue injury presents as an area of dark purple or maroon discolored, intact skin, which is caused by a pressure or shearing injury to underlying tissue.
Educational objective:
Unstageable pressure injuries have full-thickness skin loss with slough and/or eschar in the base that prevents the nurse from fully visualizing the wound depth to determine the stage. Slough and eschar must be debrided before the wound can be staged.
