Bed Sores -- Stages
The Agency for Health Care
Policy and Research, since renamed and known as AHRQ (Agency for
Healthcare Research and Quality), has adopted the most widely used
staging system, and is consistent with the National Pressure Ulcer
Advisory Panel and the International Association for Enterostomal
Therapy. The staging is as follows:
Nonblanchable erythema of intact skin; the heralding lesion of skin
ulceration. Note: Reactive hyperemia can normally be expected to be
present for one-half to three-fourths as long as the pressure
occluded blood flow to the area (Lewis,
and Grant, 1925). This should not be confused with a Stage I
Partial thickness skin loss involving epidermis and/or dermis. The
ulcer is superficial and presents clinically as an abrasion,
blister, or shallow crater.
Full thickness skin loss involving damage or necrosis of
subcutaneous tissue that may extend down to, but not through,
underlying fascia. The ulcer presents clinically as a deep crater
with or without undermining of adjacent tissue.
Full thickness skin loss with extensive destruction, tissue necrosis
or damage to muscle, bone, or supporting structures (for example,
tendon or joint capsule). Note: Undermining and sinus tracts may
also be associated with Stage IV pressure ulcers.
definitions recognize these assessment limitations:
Identification of Stage
I pressure ulcers may be difficult in patients with darkly pigmented
When eschar is present,
accurate staging of the pressure ulcer is not possible until the
eschar has sloughed or the wound has been debrided.
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