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Stage 4 Examples
Provided here are examples of different Stage 4 PUs.
Click on each example.
Example A - Trochanter
Consider/note the characteristics of this Stage 4 PU:
- indurated area indicative of infection and oedema
- thickened wound margins
- necrosis of wound margins
- depth of tissue loss
- necrosis is present within the wound
- undermining is present on palpation/probing
- wound drainage is purulent, indicative of infection.
All of the above features suggest extensive tissue damage, hence the classification of Stage 4 PU.
Example B – Heel
(Heels are difficult to stage due to the lack of soft tissue.)
Consider/note the characteristics of this Stage 4 PU:
- evidence of subcutaneous tissue (yellow cobblestone/globular tissue) and underlying bone
- clear evidence of extensive necrosis
- dense slough obscures vision; therefore, it is a Stage 4 PU.
Example C – Eschar on Heel
The presence of eschar (dead, dry thickened black tissue) over an ulcer means the full extent of the tissue damage cannot be determined without debriding.
The eschar needs to be removed before staging can proceed; often a deeper injury is masked. An ulcer covered with eschar should be classified as a Stage 4 PU until a clearer picture can be obtained.
Example D – Debrided Heel
This is the same heel as show in example C, with the eschar debrided.
Persistent slough and necrotic material covers the wound bed. The depth of tissue damage can not be visualised; hence, this is classified as a Stage 4 PU.
Example E – Sacrum
Surrounding skin shows evidence of persistent pressure around the wound.
The wound itself displays dermal tissue, thick adherent slough and necrotic tissue over the sacral-coccygeal region.
Example F – Sacrum
Surrounding skin shows evidence of persistent pressure around the wound.
The wound itself displays full thickness skin loss and presence of necrosis and tunneling
Click on the Next button to continue.
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