A record of the involvement of the different skin layers is especially significant for wounds such as pressure ulcers which can be categorised or graded, depending upon this factor (Figures 6-9). page 8 Figure 6. Category 1 skin is intact but may be discoloured and warm with oedema (swelling caused by a build-up of fluid). A localised area of non-blanchable redness may be present and is usually situated over a bony prominence. Figure 7. Category 2 presents clinically as an abrasion or blister. Partial thickness skin loss is evident and involves the epidermis and/or dermis. Figure 8. Category 3 may reach but not penetrate the underlying fascia.
Full thickness skin loss involving damage to, or necrosis of subcutaneous tissue, is evident. Figure 9. Category 4 with or without full thickness skin loss. Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures may be evident.