- What Causes Pressure Sores?
- Bony Prominences
- Types of Pressure Sores
- Types of Dressings
- Matching Game
Types of Sores.... Ouch!
Stage I Pressure Ulcer:
In a stage I pressure ulcer the skin is intact and is non-blanchable. The color may differ from surrounding skin. The skin may be tender, soft, or firm. The skin can be cool or warm compared to surrounding skin. It is important to note that pressure ulcers typically begin in bony prominences .
Stage II Pressure Ulcer:
In stage II pressure ulcers the damage is considered a partial thickness loss of tissue. This means that the damage is through the dermis (top layer of skin). This is a shallow, pinkish wound. It may be intact, open or blistered.
Stage III Pressure Ulcer:
In stage III the pressure ulcer is also called a full thickness wound. This is when the damage is so low that it goes into the fat, however, bone and tendons are not exposed.
Stage IV Pressure Ulcer:
This is also called a full thickness wound because it goes beyond the fat layer and exposes bone and/or tendons. There may be slough (which can be yellow) or eschar (black in color) tissue in the wound bed. There may also be tunneling in this level of wound, this means that as is depends it may spread further under the skin and fat layers than are visible to the naked eye.
Suspected Deep Tissue Wound:
The skin in this area is intact, the color may be purplish or maroon. It may also be a blood filled blister due to underlying damage. This area may feel mushy or boggy to the touch. Eschar may later develop on this area.
Unstageable Pressure Ulcer:
This is s a full thickness wound where the base of the wound is covered with slough and/or eschar. The slough or eschar needs to be removed to discover the true depth.