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RISK/WOUND GUIDELINES

"Pressure Ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear" (NPUAP, EPUAP, PPPIA, 2014).*
HIGH RISK CATEGORY/STAGE III - IV
MEDIUM RISK CATEGORY/STAGE I - II
LOW RISK CATEGORY/STAGE I
Stage I:Intact skin with non-blanchable redness of localized area usually over a bony prominence.
Stage II:Partial thickness skin loss (or blister) presenting as a shallow open ulcer with a red pink wound bed.
Stage III:Full thickness skin loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
Stage IV:Full thickness tissue loss with exposed bone, tendon or muscle - e.g. fascia, tendon or joint capsule. Often includes undermining and tunneling.
*National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

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