Pressure ulcer (PU) was formerly known as Bedsore (Bedsore or decubitus ulcer). The definition of pressure ulcer has been updated to read: “A pressure ulcer is a limited injury to the skin, muscle, and subcutaneous tissue caused by pressure, shear, or friction on the skin or subcutaneous tissue, often at the bony eminence.
Grade
Degree of injury and clinical manifestations
Stage I
The skin is intact with red marks that do not turn white with finger pressure
Clinical symptoms: skin is intact but red
Stage II
Epidermal or dermal damage, but not yet penetrated the dermis
Clinical signs: pain, blisters, broken skin or small shallow pits
Stage III
Total damage to epidermis and dermis, penetration into subcutaneous tissue, but not yet penetrated
Fascia and muscle layer
Clinical signs: deep irregularly shaped depressions, the base of the wound and the wound
There may be submerged pits where the edges join, and there may be necrotic tissue and exudate
But the wound base is basically painless
Stage IV
Extensive skin damage involving fascia, muscle, bone and supporting structures
Clinical signs: exposed muscle or bone, necrotic tissue may be present
Submerged deep cavity fistula, exudate
Principles of pressure sore management in stages I and II: release local pressure, improve local blood flow, protect the trauma, remove risk factors, prevent infection, and avoid progression of decubitus ulcers.
Principles of treatment for stage III and IV pressure ulcers: release local pressure, remove necrotic tissue, control trauma infection, promote granulation tissue growth, and repair surgically as soon as possible.