??? HOW ??? The staging system currently

recommended by AHRQ (AHCPR), NPUAP and WOCN (and accepted by Medicare) is a six-stage system based on the tissue layers involved

LOOK FAMILIAR?

NOW YOU KNOW WHY THERE WAS A REASON YOU MEMORISED THIS

Stage I  Defined area of non-blanchable

erythema of INTACT skin (vs. reactive hyperemia) usually over a bony prominence. Pigmented skin may not have visible blanching; its color may differ from surrounding area.The area may be painful, firm, soft (boggy) warmer or cooler than adjacent tissue. (NOT eschar)

04/24/23

Take home Words?

IntactNon-blanchableNon-necroticBoggyAnd think…..?pressure point?

Reactive Hyperemia is the red skin color that is normally

observed once pressure to an area has been relieved. This type of hyperemia is blanchable and will resolve in approximately 1/2 to 3/4 the amount of time that the area was exposed to pressure. (Increased blood supply to clear away byproducts of ischemia) e.g. a patient who is repositioned Q 2H may experience this over a bony prominence for as long as 11/2 hours following the position change.

Reactive Hyperemia Stand up: look at your fingers,

your neighbor’s crossed ankles , a leaned-upon elbow, and if you ask very politely, posterior thigh at chair edge

This is a normal process and should not be misclassified as a Stage I pressure ulcer.

Deep Tissue Injury

Manifested as deep red, maroon, purple tissue or blood-filled blister. Epidermis may or may not be intact and usually sloughs off.

Usually results from pressure/shear

NOT to be confused with Stage I

CAUTION Be careful about charting “red

sacrum” : Is it Hyperemia? Stage I? Scar? Deep Tissue Injury?