AGING & DISABILITY SERVICES ADMINISTRATION
AGING & DISABILITY SERVICES ADMINISTRATION
SKIN OBSERVATION PROTOCOL
PHOTOGRAPHS & DESCRIPTIONS OF PRESSURE ULCERS
|Stage I |Stage II |Stage III |Stage IV |
|An observable pressure-related |Partial-thickness skin loss |Full-thickness skin loss involving |Full-thickness skin loss with |
|alteration of intact skin with |involving epidermis, dermis, or|damage to or necrosis of subcutaneous|extensive destruction, tissue |
|indicators as compared to an adjacent |both. The ulcer is superficial |tissue that may extend down to, but |necrosis, or damage to muscle, |
|or opposite area on the body. These |and presents clinically as an |not through, underlying fascia. The |bone, or supporting structures |
|indicators may include changes in one |abrasion, blister, or shallow |ulcer presents clinically as a deep |(e.g., tendon, joint capsule). |
|or more of the following: skin |crater. |crater with or without undermining of|Undermining and sinus tracts may |
|temperature, tissue consistency, and/or| |adjacent tissue. |be associated with Stage IV |
|sensation. In lightly pigmented skin, | | |ulcers. |
|the ulcer appears as a defined area of | | | |
|persistent redness. In darker skin, the| | | |
|ulcer may appear with persistent red, | | | |
|blue, or purple hues. | | | |
Adapted from Statement on Pressure Ulcer Prevention Copyright, 1998. Used with permission of National Pressure Ulcer Advisory Panel.
[pic]
ADSA-CNC/NURSING SERVICES
APRIL 2003
-----------------------
• Stage 1 ulcers may not always be diagnosed reliably in patients with darkly pigmented skin.
• When eschar is present, a pressure ulcer cannot be staged accurately until eschar is removed.
• Be alert to pressure-induced pain in patients with casts or support stockings.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- disability services for college students
- department of disability services oklahoma
- department of aging and disability services
- texas dept of aging and disability services
- department of aging and disability texas
- department of aging services california
- department of disability services ct
- disability services jobs higher ed
- disability support services jobs
- aging services melbourne fl
- administration on aging statistics
- texas department of aging and disability tx