Treas 5e Sneak Preview

UNIT 4 Supporting Physiological Function

Table 32-3 ➤ Staging Pressure Injury—cont’d STAGE

CLINICAL FINDINGS

DISCUSSION

Deep Tissue Pressure Injury (DTI)

Occurs as a result of damage of underlying soft tissue from pressure or shear Findings can be subtle enough that DTI often is not recognized until after severe tissue damage has occurred. May heal or evolve further and become covered by thin eschar, rapidly exposing additional layers of tissue, even with optimal treatment. In individuals with dark skin, discoloration might go undetected. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable eschar is dry, adherent, and intact, without erythema or fluctuance. Do not remove or soften a stable eschar because it

An area of skin that is intact but persistently discolored. It might be purplish or deep red, painful, or boggy and may have a blister. Pain and temperature change often come before changes in skin color.

Unstageable Pressure Injury

Involves full-thickness skin loss The base of the wound is obscured by slough (tan, yellow, gray, green, or brown necrotic tissue) or eschar (tan, black, or brown leathery necrotic tissue).

serves as “the body’s natural cover.”

Source: Reprinted with permission. Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. Journal of Wound Ostomy Continence Nursing, 43 (6), 585–597. https://doi. org/10.1097/won.0000000000000281

■ Necrotic tissue of any type will delay wound healing and should be removed. The exception is stable eschar on a heel that is firmly attached to the healthy wound edges without signs of infection. Drainage Determine whether exudate is present. If so, describe the amount, color, consistency, and odor.

■ Many wounds may have different types of tissue at the same time. Describe each type with percentages. For example, “80% of the wound bed contains granu- lation tissue, and 20% remains necrotic.” ■ Granulation tissue is evidence of healing. ■ A pale color or dry texture may indicate a delay in healing.