Master Pressure Ulcers with Picmonic for Nursing RN

In this stage the skin is still intact. This is typically the first indication of skin breakdown, and frequent turns should be initiated while avoiding putting pressure on the reddened area. To determine if the reddened area is a stage one, push a finger into the reddened area. If the skin does not turn white, then it has entered into stage one.

In stage two, the ulcer can be classified as partial thickness open or partial thickness closed. The ulcer will either develop a blister (closed) or become an open sore. Skin is not intact at this stage and at risk for becoming infected.

In stage three the ulcer has cratered into the dermis and subcutaneous tissue. Fat could be visible with sloughing of the tissue. Nerve damage can also occur at this stage.

Bone is exposed in stage four. Slough and eschar may be present. The wound could also have undermined or tunneled into the surrounding tissue.

Wounds are unstageable when the depth of the wound cannot be determined. This is typically due to dead tissue covering the ulcer like a scab. The dead tissue needs to be removed by the physician or a wound specialist before staging can occur.

This can occur when the skin looks like a deep bruise. This is not to be confused with Stage one pressure ulcers, as the skin is more purplish or maroon. These types of injuries should be reported to the doctor immediately for these injuries can quickly turn into a Stage three or four pressure ulcers.

It is important to remember that blanching is not always apparent in patients with dark-pigmented skin. Assessing for an increase in warmth, pain, or skin firmness are other indicating of skin breakdown.

Necrotic tissue needs to be removed before staging, because it can cover up the true depth of the wound. The physician or wound nurse specialist will recommend treatment in this case. It is also important to remember that once a wound is staged, the wound will always be classified as its highest stage type until fully healed.
Example: A wound became a stage three before it started healing. Even though the wound has healed to a stage one, it is still considered a stage three.