Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Pressure ulcer of trochanter – Stage IV; 80% – 90% slough; undermining 3 cm at 10 o’clock; margins with re-epithelialization; edible (rolled edges).
Hi Laurie, Typo alert- please correct to epibole
How often do u silver nitrate a rolled edge in a chronic undermined full thickness sacral pressure injury in the LTAC type patient(trach / peg, bedbound, Braden 7, etc…) within the acute care setting?
Can u point me in the right direction to determine all tissue types that are yellow/white pigment? For example, fibrinous slough, deep dermis, subcutaneous, and the superficial thin yellow tissue that sits in top of a healing wound???
Thank you!
Looking at the above picture the 80% slough must be just the wound and you are not counting the thick rolled edge?
Can you suggest other picture sites to learn more about identifying wounds as I am doing a course that requires IDing wounds and they have not really given us many pictures. thx
Cynthia, please see our resources tab, https://woundeducators.com/resources/ for more images. Best of luck!