SIGNS OF A PRESSURE ULCER
The first sign of a pressure area is often a reddened area over a bony prominence. The reddened area will not go away even the pressure is relieved (e.g. the person is repositioned). There may be other symptoms, such as pain or a difference in temperature when compared to the surrounding area. The injured area may be warmer or cooler, firmer or softer than the surrounding skin. There could be burning, itching or tingling in the area.
It is difficult to detect the early stages of a pressure ulcer in persons with dark skin. The damaged area may appear to be a different color than the surrounding skin.
The more advanced pressure ulcers can involve breakdown of the skin, the tissues that lie below the skin and even the bone. There may be drainage from the ulcer. Skin can actually decay with severe pressure ulcers.
Pressure ulcers are usually found on bony prominences. A bony prominence is an area where the bone sticks out. Bony prominences are also called pressure points because they bear the weight of the body when a person is sitting or lying down.
The most common location for a pressure ulcer in adults is the coccyx or sacrum. The heel is the second most common site. Pressure ulcers, however, can be found in other parts of the body including the elbows, shoulder blades, hips, knees, ankles, toes or ear lobes. Pressure areas can also develop where two bony surfaces, such as the knees and ankles, rub together. In obese persons a pressure area can develop from the friction of skin rubbing against skin (e.g. under the breasts).
STAGING
A pressure ulcer can range in severity from a minor injury that does not cause a break in the skin to a deep injury affecting muscle and sometimes even bone. Pressure ulcer development can be broken down into four stages based on the degree and depth of the injury:
Stage I
This is the stage with the least serious injury. The skin remains unbroken in this stage. There is redness in a localized area, usually situated over a bony prominence. The color does not revert to normal when the pressure is relieved (e.g. the person is turned). If the person has a dark skin tone, the color of a stage 1 ulcer may appear to be different from that of the surrounding skin. The damaged area may feel firmer or softer than the skin next to it. It may also be a different temperature than the surrounding area.
Stage II
The skin is broken although the wound is not deep. May appear as a shallow ulcer. There could be a blister which is either intact or broken.
Stage III
This is a deeper injury. The tissue below the skin may be exposed although bone, tendon or muscle will not be visible. There may be some drainage. In locations where there is not much subcutaneous tissue, such as the earlobe or the bridge of the nose, the stage III ulcer will be shallow.
Stage IV
A very deep injury exposing bone, tendon or muscle. Drainage or eschar (a dry crust) may be present. If the ulcer involves the bone, the injury is more serious. Again, in areas with little or no subcutaneous tissue, the stage IV ulcer can be shallow.
Unstageable
Some pressure ulcers are labelled as unstageable. These injuries are hidden by dead tissue or a dry crust, making it difficult to determine the exact extent of the injury. The injury could be either a stage III or a stage IV.
