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Decubitus Levels Illustrated Cheat Sheet by

medical     healthcare     decubitus     illustrated

Introd­uction

Pressure ulcers, also known as pressure sores, bedsores and decubitus ulcers, are localized injuries to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combin­ation with shear and/or friction. The most common sites are the skin overlying the sacrum, coccyx, heels or the hips, but other sites such as the elbows, knees, ankles or the back of the cranium can be affected.

Normal Skin Layers

Stage 1

Intact skin with non-bl­anc­hable redness of a localized area usually over a bony promin­ence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrou­nding area. The area differs in charac­ter­istics such as thickness and temper­ature as compared to adjacent tissue. Stage I may be difficult to detect in indivi­duals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk).

Stage 2

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/r­uptured serum-­filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermat­itis, maceration or excori­ation.
 

Stage 3

Full thickness tissue 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 & tunneling. The depth varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcut­aneous tissue and stage III ulcers can be shallow. In contrast, areas of signif­icant adiposity can develop extremely deep stage III pressure ulcers.

Stage 4

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include underm­ining and tunneling. The depth varies by anatomical location. Ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteom­yelitis likely to occur. Exposed bone/t­endon is visible or directly palpable.

Suspected Pressure Sore

A purple or maroon localized area of discolored intact skin or blood-­filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve & become covered by thin eschar and eventually expose additional layers of tissue even with optimal treatment.

Unstag­eable

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determ­ined. Stable (dry, adherent, intact without erythema or fluctu­ance) eschar on the heels is normally protective and should not be removed.

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