Wound and Skin Assessment Mary Carvalho RN, BSN, MBA Clinical Coordinator Johnson Creek Wound and Edema Center. Stage 1 Pressure Ulcer Intact skin with Nonblanchable redness Of a localized area Grade 1 The grade 1 foot has a superficial ulcer.
Pictures of pressure ulcers and disease information have been excerpted from VisualDx clinical decision support system as a public health service. Additional information, including symptoms, diagnostic pearls, differential diagnosis, best tests, and management pearls, is available in VisualDx.
A pressure sore has begun if you remove pressure from the reddened area for 10 to 30 minutes and the skin color does not return to normal after that time.
Stay off the area and follow instructions under Stage 1, below. Decubitus ulcers (or pressure sores or bed sores) are preventable injuries to skin tissue. These pressure sore injuries open the body up to further infection and disease, often resulting in death or amputation. Pressure sores are broken down into 4 stages: Feb 25, 2006 A pressure ulcer is defined by the European Pressure Ulcer Advisory Panel as an area of localised damage to the skin and underlying tissue caused by pressure, shear, or friction, or a combination of these.
Grade 1 Pressure Ulcers At this stage the pressure ulcer presents itself by the skin turning into a red colour, similar to the skin immediately after a minor burn.
The skin may also appear a little harder than usual and than the surrounding areas. Pressure ulcers are categorized into four stages by the National Pressure Ulcer Advisory Panel depending on the level of tissue involvement or depth of the sore. The tissue being referred to includes the skin and underlying dermis, fat,