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Pressure Ulcer Stages and documentation

Teacher: Portia Mathews
Horizontales
Full Thickness tissue loss involving epidermis,dermis but not subq.
Shiny or dry open ulcer with a pink or red base
Name risk assessment tool
Skin surrounding the wound
Verticales
Wound bed covered by devitalized tissue
Full thickness tissue loss with subq, bone,tendon, or muscle exposed
Skin updates are due
Non blanchable erythema skin
Moisture Associated Skin Damage