Neuro

Suspected Deep Tissue Injury (DTI):

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

DTI may be difficult to see in individuals with dark skin tones. The wound may be a thin blister over a dark wound bed. The wound may further evolve to an eschar. The evolution may be rapid even with optimal treatment.

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Stage I Pressure Ulcer:

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons- this may be the first sign of risk.

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♦ protective barrier ointment

♦ skin prep

♦ transparent dressing (Tegaderm)

♦ Xenaderm ointment

♦ foam dressing (Mepilex) for padding

Stage II Pressure Ulcer:

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough or bruising. May also present as an intact or open/ruptured serum filled (clear) blister. This should not be used to describe skin tears, maceration, tape burns, excoriation, or perineal dermatitis

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protective barrier ointment

♦ transparent dressing (Tegaderm Transparent)

♦ Normal Saline dampened dressing

♦ Hydrocolloid (Tegaderm Hydrocolloid)

♦ Hydrogel (Curasol)

♦ Foam (PolyMem, Mepilex)

♦ Xenaderm ointment

♦ Composite Dressing (Combiderm)

Stage III Pressure Ulcer:

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure...