Wound Stages
| A complete assessment of skin is essential to an effective wound prevention and management program. Follow steps one through five to assess a pressure ulcer and complete Section M of the MDS 3.0 | |
| STEP 1: | Assess pressure ulcer risk per facility protocol |
| STEP 2: | Stage pressure ulcers. Determine the deepest anatomical stage for each pressure ulcer. Do not reverse or back stage. |
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Stage 1 - MO 300A
Pressure related alteration of intact skin with non-blanchable redness of localized area, usually over a bony prominence. |
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Stage 2 - MO 300B
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister. |
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Stage 3 = MO 300C
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include tunneling and/or undermining. |
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Stage 4 - MO 300D
Full thickness tissue loss with exposed bone, tendon, muscle. Slough or eschar may be present. Often includes tunneling and/or undermining. |
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Unstageable related to non-removable dressing - MO 300E
Non-removable dressing/device includes, for example, a primary surgical dressing, negative pressure dressing, an orthopedic device or cast. |
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Unstageable related to slough - MO 300F
Slough is non-viable yellow, tan, gray or brown tissue. Slough is usually moist and can be soft and string in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. |
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Unstageable related to eschar - MO 300F
Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown or tan in color. Necrotic tissue and eschar are usually firmly adherent to the base, sides and edges of the wound. |
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Unstageable related to suspected Deep Tissue Injury(DTI) - MO 300G
Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be surrounded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. |
| STEP 3: | Assess Tunneling and/or Undermining |
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Tunneling - Passage way of tissue destruction under the skin. |
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Undermining - Tissue destruction extending under wound edges. Undermining and tunneling are not recorded on the MDS 3.0 |
| STEP 4: | Measure unhealed and unstageable pressure ulcers. Calculate surface area. MO 610 |
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Measure every Stage 3 or 4 and unstageable pressures ulcer due to slough or eschar. Determine longest length (head to toe) and greatest width (side to side). Calculate surface area by multiplying length X width. Select largest ulcer and measure depth. Enter length, width and depth of largest pressure ulcer in MO 610 |
| STEP 5: | Identify most severe Tissue Type present in pressure ulcer bed. MO 700 |
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Epithelial - New skin that is light pink and shiny |
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Granulation - Red tissue with "cobblestone or bumpy appearance bleeds easily. |
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Slough - Non viable yellow, tan, gray or brown tissue; usually moist, can be soft, stringy. |
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Eschar - Dead or devitalized black, brown tissue; usually hard and firmly adherent to the base of the wound. |
