A pressure ulcer, commonly called a bedsore, is an injury to the skin and any underlying tissues. It results from excessive pressure over time and is found on the heels, sacrum, ankles, hips and vertebrae. A pressure ulcer most commonly occurs over any bony prominence, especially when there is a lack of circulation. Even though it can happen to anyone, it most commonly occurs in individuals who have impaired mobility and consciousness, have thinner skin, are unable to respond to pain, and/or are incontinent (Jarvis, 2016).
Stage I
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The skin remains intact (Jarvis, 2016).
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Some localized redness, but the skin does not blanch (Jarvis, 2016).
(Jarvis, 2016)
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The epidermis, is the first thin outer layer of the skin (Jarvis, 2016).
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The dermis, the second layer, is mostly made up of collagen or connective tissue. This protein allows the dermis to be supportive. All nerves, blood vessels and lymphatics lie here (Jarvis, 2016).
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The subcutaneous tissue is located under the dermis. This is made up of adipose tissue which stores fat for energy and provides temperature control (Jarvis, 2016).
Layers of the skin
Jarvis, 2016
CLASSIFICATION OF A WOUND
There are many ways to classify a wound using a wound assessment:
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Depth (Partial versus Full Thickness wound)
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Acuity (acute versus chronic)
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Ulceration (Arterial, Venous, Diabetic, and Pressure)
PRESSURE ULCER STAGING
What do they look like?
3M House. (2016). Retrieved October 15, 2016, from http://solutions.3m.co.uk/wps/portal/3M/en_GB/skin-care/wound-resource-
centre/chronic-wounds/leg-ulcers/arterial/
Ignatavicius, D. D., Workman, M. L., Blair, M., Rebar, C. R., & Winkelman, C. (2016). Medical-surgical nursing: Patient-centered
collaborative care. St. Louis, Missouri: Elsevier.
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). St. Louis, Missouri: Elsevier.
Byrd, L. (2012, June 25). CC Wound Identification: Differentiating Types of Ulcers: Arterial, Venous, Diabetic, &
Pressure., 33(3), 235-242. http://dx.doi.org.authenticate.library.duq.edu/10.1016/j.gerinurse.2012.03.010
Web MD (2014, November 14). Retrieved October 15, 2016, from http://www.webmd.com/diabetes/diabetic-foot-ulcer
Wound Care Worcester (2016). Retrieved October 15, 2016, from http://woundcareworcester.com/service/venous-ulcer/
WHAT IS A PRESSURE
ULCER?
Identify the stages of a pressure ulcer and tell the difference between pressure ulcers and partial/full thickness wounds.