MDS Alert

Compliance:

Know the RAI Manual Definitions for Stage 1 Pressure Ulcers

The RAI User's Manual includes the following definitions:

"STAGE 1 PRESSURE ULCER: An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues."

"NON-BLANCHABLE: Reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device."

The manual also states: "Reliance on only one descriptor is inadequate to determine the staging of the pressure ulcer between Stage 1 and suspected deep tissue ulcers. The descriptors are similar for these two types of ulcers (e.g., temperature (warmth or coolness); tissue consistency (firm or boggy)."

Source: Page M-7, RAI User's Manual. Review information on deep tissue injury on page M-18 and M-19.