Skin Care Fair Instruction Guide
Further Description: Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicated suspected deep tissue injury). This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
3. Stage III: Orange
Description: To simulate a Stage 3 ulcer, use potato peeler to remove all of the rind in one area and slightly break through to the fruit.
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Further Description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
4. Stage IV: Orange
Description: Use the potato peeler to break through the rind and create a deep wound into the orange. The area on this orange represents a Stage 4 pressure ulcer. Not only is the rind broke, but the damage goes deep into the fruit of the orange.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Further Description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.