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Pressure Injury: Localized damage to the skin and underlying tissue occurring as a result of intense and/or prolonged pressure with or without shear.
PRESSURE INJURY CLASSIFICATION:
- STAGE I – Patients identified as being at risk for the development of a pressure injury or intact skin with reddened area non-blanchable-
STAGE II – partial thickness loss of dermis presenting as shallow open injury with a pink red wound bed without slough, may also present as an intactor open/ruptured serum filled blister
- STAGE III – full thickness skin loss, subcutaneous fat may be visible; but bone, tendon, or muscle are not; slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling
- STAGE IV – full thickness skin loss, with exposed muscle, tendon, or bone. Slough or eschar may be present, often includes undermining or tunneling.
- UNSTAGEABLE – Full thickness tissue loss in which the base of the injury is covered by slough and/or eschar in the wound bed
- DEEP TISSUE INJURY (DTI) - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or sheer