How would you stage this pressure ulcer is and why?

Nice work everyone and thank you for posting. This pressure ulcer would be staged as a suspected deep tissue injury (STDI). According to NPUAP, the definition of a SDTI is: "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."

For more information about staging view the video.

Tags: pressure ulcer

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Permalink Reply by Melinda McIntosh on April 20, 2011 at 10:48am

Unstageable.

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Permalink Reply by Ellen Marie Sundstrom on April 20, 2011 at 11:29am

Unstageable

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Permalink Reply by Valerie Weart, RN, WCC on April 20, 2011 at 12:08pm

This is a suspected deep tissue injury. Staged according to NPUAP definitions, "Purple or maroon localized area of discolored intact skin or blood-filled blister".

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Permalink Reply by Rosalind Casillas RN on April 20, 2011 at 12:14pm

deep purple discoloration, unstageable wound, we don't know what is under this pressure ulcer

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Permalink Reply by Angelos Karatzias on April 20, 2011 at 2:26pm

could be stage 3 or stage 4 but generally the term unstageable is better

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Permalink Reply by Wynell thomas on April 20, 2011 at 4:54pm

This wound is unstagable

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Permalink Reply by Bintah Diallo on April 20, 2011 at 6:46pm

I would say this is a deep tissue injury on the left medial heel with a blister that is in tact on the heel with the measurement of the DTI and the area of the blister.

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Permalink Reply by Michelle Shannon RN, BSN on April 20, 2011 at 8:00pm

Suspected deep tissue injury.

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Permalink Reply by Emily F. Callahan,R.N. on April 20, 2011 at 8:26pm

nonstageable. The structures below the surface cannot be visualized, therefore the tissue destruction cannot be assessed.

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Permalink Reply by Dianne Sommers on April 20, 2011 at 10:49pm

Unstageable deep tissue injury.

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Permalink Reply by Mary Curtius on April 21, 2011 at 6:51am

Looking at the picture, presently it is a stage 1 due to it is not open. If the heel wound were to be opened, I would estimate it to be a stage 3 almost a stage 4. You can tell by the looks of it that there is definitely deep tissue involvement but, does not appear to possibly be all the way to the bone. The other area on the achilles tendon area I would estimate at probably a stae 2 if it were open. It does not appear to be as deep as the heel.