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CHAPTER 32 Skin Integrity & Wound Healing
Table 32-3 ➤ Staging Pressure Injury—cont’d STAGE
CLINICAL FINDINGS A deep crater characterized by full- thickness skin loss with damage or necrosis of subcutaneous tissue. Adipose is visible. May extend down to, but not through, underlying fascia Undermining (deeper-level damage under boggy superficial layers) of adjacent tissue may be present. Bone/tendon is not visible or directly palpable. Involves full-thickness skin loss, with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures Exposed bone/tendon is visible or directly palpable. Slough or eschar (tan, black, or brown leathery necrotic tissue) may be present. Epibole (rolled edges), undermining, and sinus tracts (blind tracts underneath the epidermis) are common.
DISCUSSION
Stage 3 Pressure Injury
Some stage 3 pressure injuries can be extremely deep when located in an area with significant adipose layers.
Stage III
Stage 4 Pressure Injury
The depth of a stage 4 pressure injury varies by location.They can be shallow on the bridge of the nose, ear, occiput, and malleolus because these areas do not have subcutaneous tissue. Stage 4 injuries can extend into muscle and supporting structures (e.g., fascia, tendon, or joint capsule). Often requires a full year to heal. Even once healed, the site remains at risk for future injury because the scar tissue is not as strong as the original tissue.
Stage IV
:
(Continued)
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