16
UNIT 4 Supporting Physiological Function
Table 32-3 ➤ Staging Pressure Injury STAGE
CLINICAL FINDINGS
DISCUSSION
Stage 1 Pressure Injury
Dark skin may not have visible blanching (becomes pale when light pressure is applied); its color may differ from that of the surrounding area. Therefore, stage 1 may be difficult to detect.
Localized area of intact skin with nonblanchable redness (does not become pale under applied light pressure),
Epidermis
Dermis Fat Muscle
usually over a bony prominence, but not maroon or purple discoloration
Bone
The area may be painful, firm, soft, or warmer or cooler compared with adjacent tissue. Discoloration will remain for more than 30 minutes after pressure is relieved.
Stage I
Stage 2 Pressure Injury
Do not use this stage to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. Do not mistake moisture-associated skin damage or fungal infections for stage 2 pressure injury. Stage 2 pressure injury does not involve sloughing or bruising.
Involves partial-thickness loss of dermis Stage 2 pressure injury is open but shallow and with a reddish-pink wound bed. There is no slough (tan, yellow, gray, green, or brown necrotic tissue). May also be an intact or open/ruptured serum- filled blister or a shiny or dry shallow ulcer without slough or bruising
Stage II
49
Powered by FlippingBook