Module 4 Program Segment 2 of 3 - Home Care Information Network

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Home Care Information Network www.homecareinformation.netUltimate OASIS-C Training Item by Item [Rev 2/11]2/13/2011Stage IV Pressure Ulcer• The bridge of the nose, ear,occiput, and malleolus donot have subcutaneoustissue; Stage IV ulcers inthese locations can beshallow. Stage IV ulcers canextend into muscle and/orsupporting structures (eg,fascia, tendon, or jointcapsule); osteomyelitis ispossible. Exposedbone/tendon is visible ordirectly palpable.Unstageable• Known or likely but not stageable due tonon-removable dressing or device• Known or likely but not stageable due tocoverage of wound bed by slough and/oreschar.• Suspected deep tissue injury in evolution.Unstageable #d2• Full-thickness tissue loss in which the base ofthe ulcer is covered by slough (yellow, tan,gray, green or brown) and/or eschar (tan,brown or black) in the wound bed may rendera wound unstageable.• Further description. Until enough sloughand/or eschar is removed to expose the baseof the wound, the true depth (and therefore,the stage) cannot be determined. Stable (dry,adherent, intact without erythema orfluctuance) eschar on the heels serves as“the body’s natural (biological) cover” andshould not be removed.© Lisa Selman-Holman 6
Home Care Information Network www.homecareinformation.netUltimate OASIS-C Training Item by Item [Rev 2/11]2/13/2011Unstageable #d2Suspected Deep TissueInjury• Suspected deep tissue injury in evolution, which isdefined by the NPUAP as a purple or maroon localizedarea of discolored intact skin or blood-filled blister due todamage of underlying soft tissue from pressure and/orshear. The area may be preceded by tissue that ispainful, firm, mushy, boggy, warmer, or cooler ascompared to adjacent tissue. Deep tissue injury may bedifficult to detect in individuals with dark skin tones.Evolution may include a thin blister over a dark woundbed. The wound may further evolve and becomecovered by thin eschar. Evolution may be rapid exposingadditional layers of tissue even with optimal treatment.Suspected DTI© Lisa Selman-Holman 7
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Module 4 Program Segment 2 of 3 - Home Care Information Network

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