Q) Pressure sore, grade II is

a) Partial thickness skin loss, epidermis and dermis are involved

b) Full thickness skin loss, involving subcutaneous tissue but not underlying fascia

c) Non blanchable erythema, no breach in epidermis

d) Involvement of bones and tendons

Ans a

Pressure sores occurs when ext pressure exceeds the capillary occlusive pressure (30 mmHg) approximately 5% of all hospitalised patients

Stage                   Description

1                        Non-blanchable erythema without a breach in the epidermis

2                       Partial-thickness skin loss involving the epidermis and dermis

3                       Full-thickness skin loss extending into the subcutaneous tissue but not through underlying fascia

4                        Full-thickness skin loss through fascia with extensive tissue destruction, maybe involving muscle, bone, tendon or joint

Bailey - page 29


Pressure sore
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