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.

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ADSA-CNC/NURSING SERVICES

APRIL 2003

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• 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.

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