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6 Stages of Pressure Ulcers

Pressure ulcers, also known as decubitus ulcers or bedsores, are injuries to the skin and underlying tissue caused by prolonged pressure on the skin, usually over bony prominences such as the sacrum and heels. They are commonly seen in bedridden and/or incontinent patients.

The 6 stages of pressure ulcers or injury are as follows:

Stage 1 pressure ulcer: The skin appears red but remains intact. When pressed, the area does not blanch or turn white (known as "nonblanchable erythema").

Stage 1 pressure ulcer

Stage 2 pressure ulcer: Partial-thickness skin loss, with a shallow open wound or blister.

Stage 2 pressure ulcer

Stage 3 pressure ulcer: Full-thickness skin loss with damage extending to subcutaneous tissue. Undermining and tunneling may or may not be present.

Stage 3 pressure ulcer

Stage 4 pressure ulcer: Full-thickness skin loss with exposed muscle, tendon, and bone. Slough or eschar may be present, and undermining and tunneling may develop.

Stage 4 pressure ulcer

Stage X or unstageable pressure ulcer: The depth of the ulcer is unknown because the base of the wound is covered by slough (yellow, tan, grey, green, or brown) and an eschar (tan, brown, or black).

Stage X or Unstageable

Suspected deep tissue injury: The skin is intact (unbroken) but may have a blister and appears purple or maroon. The tissue beneath is damaged (stage 3 or 4) and may feel painful, mushy, boggy, warmer, or cooler.

Suspected Deep Tissue Injury

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NCLEX: National Council Licensure Examination, OIIQ: Ordre des infirmières et infirmiers du Québec, OIIAQ: Ordre des infirmières et infirmiers auxiliaires du Québec

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