Stage I Pressure Ulcers Change in color, consistency, or temperature of the skin. Possibly only detected by tactile exam. Skin is intact and the underlying tissues are unaffected. Warning sign: Intereventions are preventative of future skin issues.Stage IV Pressure Ulcers Extend into the subcutaneous tissue with involvement of bone, muscle, and fascia

Stage II Pressure Ulcers Involvement of epidermal layer of skin, and may extend to dermis May appear as shallow, open areas or intact serum-filled or serosanguineous blisters. Break of skin integrity Often requires serous drainage and localized dermatologic issuesUnstageable Pressure Ulcers If unable to visualize bottom of ulcer due to covering by thick necrotic tissue or scabbing, staging is not possible Only can stage with debridement

Stage III Pressure Ulcers Extend into the subcutaneous tissue but there is no involvement of bone, muscle, and fascia (may be visible) If Stage II in appearance but with necrotic slough in the ulcer May involve tunneling and underminingUnstageable Pressure Ulcers Surface appears as Stage I or II pressure ulcer, but there is severe damage to underlying tissues is severe, with possible internal necrosis. Most common at interface between bone and soft tissue Surface skin can quickly advance to stage II or IV High suspicion with large ulcers and low braden scores

Pressure ulcer (Bedsore; Decubitus ulcer) Measure Braden Scale (1-4 for each criteria; lower scorer=worse) Sensory Perception- Ability to process/ communicate input from skin Moisture-Exposure to moisture Activity- Level of activity (irrespective of mobility) Mobility- Ability to change/control body position Nutrition- Usual pattern/amount of caloric intake Friction and Sheer- How they move within confines Treatment Eliminate external pressure while maintaining local tissue integrity Facilitate natural healing while removing necrotic tissue Adequate pain relief Reducing Bacterial load Treating underlying condition