Stage That Wound!
This stage is defined by non-blanchable redness over a bony prominence.
What is a Stage 1?
A stage 1 will not do this when you press on the skin.
What is blanch?
A skin tear or IAD is often mistaken for this pressure injury stage.
What is a stage 2?
This skin layer affected in a stage 1 pressure injury.
What is the epidermis?
This scale helps assess pressure injury risk.
What is the Baden Scale?
This stage shows partial thickness skin loss involving the epidermis and/ or dermis.
What is a stage 2?
Yellow, tan, green, or brown tissue that may cover a wound bed and obscure depth.
What is slough?
This stage can be mistaken for a bruise but results from pressure and shear.
What is a deep tissue injury?
This tissue is exposed in stage 3 pressure injury but not in stage 2.
What is subcutaneous tissue?
This bony area is the most common site for pressure injuries.
What is the sacrum?
This stage cannot be determined due to slough or eschar.
What is Unstageable?
A wound with purple or maroon discoloration and potential blood blister over a bony prominence.
What is a deep tissue injury?
This cannot be used to determine the stage of the pressure injury.
What is the wound size?
You can see this deep tissue structure in a stage 4 pressure injury.
What is bone, muscle or tendon?
Turning patients every __ hours helps prevent pressure injuries.
What is 2?
This stage involves exposed bone, muscle or tendon.
What is a stage 4?
What is a stage 4?
This staging term should never be used to describe wound healing progress.
What is reverse staging?
This dry, black tissue often covers unstageable pressure injuries.
What is eschar?
This skin condition results from prolonged exposure to moisture but is not a pressure injury.
What is incontinence associated dermatitis (IAD)?
Full-thickness skin loss exposing subcutaneous tissue but not muscle or bone.
What is a stage 3?
Moisture, friction, and this mechanical force contributes to pressure injury risk.
What is shear?
This type of pressure injury results from oxygen tubing, catheters or BiPAP mask.
What is a medical device related pressure injury?
This structure lies between bone and skin and is at high risk for deep tissue damage.
What is muscle?
This should be performed every shift to assess skin integrity in at risk patients.
What is a head to toe assessment?