RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Assessment & Management of Stage I to IV Pressure UlcersEpithelialization: The stage of tissue healing in which epithelial cells migrate (move) across thesurface of a wound. During this stage of healing, the epithelium appears the colour of “ground glass”to pink (AHCPR, 1994).Erythema: Redness of the skin.Blanchable Erythema: Reddened area that temporarily turns white or pale when pressure is appliedwith a fingertip. Blanchable erythema over a pressure site is usually due to a normal reactivehyperemic response (AHCPR, 1994).Nonblanchable Erythema: Redness that persists when fingertip pressure is applied. Nonblanchableerythema over a pressure site is a symptom of a Stage I pressure ulcer (AHCPR, 1994).Eschar: Thick, hard, black, leathery, necrotic, devitalized tissue (AHCPR, 1994).Fascia: A sheet or band of fibrous tissue that lies deep below the skin or encloses muscles andvarious organs of the body (AHCPR, 1994).Fluctuance: Wavelike motion, indicative of the presence of fluid, used to describe the appearanceof wound tissue (AHCPR, 1994).Friction: Mechanical force exerted when skin is dragged across a coarse surface such as bed linens(AHCPR, 1994).Full Thickness Tissue Loss: The absence of epidermis and dermis (AHCPR, 1994).Granulation Tissue: The pink/red, moist tissue that contains new blood vessels, collagen, fibroblasts,and inflammatory cells, which fills an open, previously deep wound when it starts to heal (AHCPR, 1994).Growth Factors: Proteins that affect the proliferation, movement, maturation, and biosyntheticactivity of cells. For the purposes of this guideline, these are proteins that can be produced by livingcells (AHCPR, 1994).72