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??? HOW ???. The staging system currently recommended by AHRQ (AHCPR), NPUAP and WOCN (and accepted by Medicare) is a six-stage system based on the tissue layers involved. LOOK FAMILIAR? NOW YOU KNOW WHY THERE WAS A REASON YOU MEMORISED THIS. Stage I.

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  1. ??? HOW ??? • The staging system currently recommended by AHRQ (AHCPR), NPUAP and WOCN (and accepted by Medicare) is a six-stage system based on the tissue layers involved

  2. LOOK FAMILIAR? NOW YOU KNOW WHY THERE WAS A REASON YOU MEMORISED THIS

  3. Stage I •  Defined area of non-blanchable erythema of INTACT skin (vs. reactive hyperemia) usually over a bony prominence. Pigmented skin may not have visible blanching; its color may differ from surrounding area.The area may be painful, firm, soft (boggy) warmer or cooler than adjacent tissue. (NOT eschar)

  4. Take home Words? Intact Non-blanchable Non-necrotic Boggy And think…..?pressure point?

  5. Reactive Hyperemia • is the red skin color that is normally observed once pressure to an area has been relieved. This type of hyperemia is blanchable and will resolve in approximately 1/2 to 3/4 the amount of time that the area was exposed to pressure. (Increased blood supply to clear away byproducts of ischemia) e.g. a patient who is repositioned Q 2H may experience this over a bony prominence for as long as 11/2 hours following the position change.

  6. Reactive Hyperemia • Stand up: look at your fingers, your neighbor’s crossed ankles , a leaned-upon elbow, and if you ask very politely, posterior thigh at chair edge • This is a normal process and should not be misclassified as a Stage I pressure ulcer.

  7. Deep Tissue Injury • Manifested as deep red, maroon, purple tissue or blood-filled blister. Epidermis may or may not be intact and usually sloughs off. • Usually results from pressure/shear • NOT to be confused with Stage I

  8. CAUTION • Be careful about charting “red sacrum” : Is it • Hyperemia? • Stage I? • Scar? • Deep Tissue Injury?

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