Chp. 36. pgs. 922-924

Stage 1-  nonblanchable erythema signaling potential breakdown.

Stage II- partial thickness, skin loss, (abrasion, blister or shallow crater involving epidermis & possibly the dermis.

Stage III- Full-thickness skin loss involving damage or necrosis that may extend down to, but not through underlying fasia.

Stage IV- full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures such as tendon or joint capsule

1. Primary intention healing-occurs when the tissue surfaces have been approximated(closed) and there is minimal or no tissue loss.

2. Secondary intention healing- wound that is extensive & involves considerable tissue loss

Sensory perception-ability to respond meaningfully to pressure-related discomfort.

Moisture-degree to which skin is exposed to moisture

Activity- degree of physical activity

Mobility- ability to change & control body position.

Nutrition- usual food intake pattern

• Friction & Shear- 
• Adult who scores >18 is considered at risk. Total of 23 pts is possible.