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Notes

Stage I
  • Intact, nonblanching erythematous area.
  • Indicates potential for ulceration.
  • No dressing required: Assess frequently.
  • Prevent continued pressure or shearing forces.
  • Assess frequently.

    4625_C_UF02_09.jpg

Stage II
  • Interruption of epidermis, dermis, or both.
  • Presents as abrasion, blister, or very shallow crater.
  • Use dressing that will keep ulcer bed moist.
  • Keep surrounding intact skin dry.
  • Fill wound dead space with loosely packed dressing to absorb excess drainage and maintain moist environment.

    4625_C_UF02_10.jpg

Stage III
  • Full-thickness crater.
  • Involves damage and/or necrosis down to, but not penetrating, fascia.
  • Same as stage II plus debride eschar and necrotic tissue.
  • Note: Heel ulcers with dry eschar and no edema, erythema, or drainage may not need to be debrided.
  • Debridement may be done surgically, with enzymatic agents, or mechanically with wet-to-dry dressings, water jets, or whirlpool. Do not use topical antiseptics.

    4625_C_UF02_11.jpg

Stage IV
  • Full-thickness crater.
  • Similar to stage III, but penetrates fascia and involves muscle and bone.
  • May involve undermining.
  • Same as stages II and III plus remove all dead tissue, explore undermined areas, and remove skin "roof."
  • Use clean, dry dressings for 8-24 hr after sharp debridement to control bleeding; then resume moist dressings.

    4625_C_UF02_12.jpg