Pressure Ulcers: First Indication might be blanching where the area becomes pale and white also called ischemia.
Friction-Occurs when two surfaces rub against each other
Shearing force- Results when one layer of tissue slides over another layer (repositioning a patient by yourself)
Stage 1- Defined area of intact skin with non blanchable redness of a localized area, usually over a bony prominence such as the elbow, heels, tailbones, or hips. Area might be painful, firm, soft, warmer or cooler compared to other tissue. Darker skinned people may not have visible blanching.
Stage 2- Involves partial thickness loss of dermis, superficial, may present as a blister or a abrasion or open ulcer with red/pink wound bed, without slough.
Stage 3- Full thickness tissue loss, subcutaneous fat may be visible, may include tunneling
Stage 4- Full thickness tissue loss, exposed bone, tendon or muscle, often includes tunneling or holes as big as fist. Slough and eschar may be present on some parts of the wound bed. (thick leatherly scab or dry, crust that has necrotic and has to be removed.)
UNSTAGEABLE- Full thickness tissue loss, base of the ulcer is covered by slough and or eschar in the wound bed