Verbal (V) - The best verbal response, with responses ranging from 5 to 1ĥ = Conversation is coherent and oriented.Ĥ = Conversation is incoherent and disoriented.ģ = Words are spoken, but inappropriately. Is calculated by using appropriate stimuli (a painful stimulus may be necessary) and then assessing the clients response in three areas.Įye opening (E) - The best eye response, with responses ranging from 4 to 1ģ = Eye opening occurs secondary to voice.Ģ = Eye opening occurs secondary to pain. ◯ Unstageable - No determination of stage because eschar or slough obscures the wound. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). ◯ Stage IV - Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle,īone, or supporting structures.

The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. The ulcer may extend down to, but not through, underlying fascia. ◯ Stage III - Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. ◯ Stage II - Partial-thickness skin loss involving the epidermis and the dermis. With darker skin tones, the ulcer may appear blue or purple.

The tissue is swollen and has congestion, with possible discomfort at the site. ◯ Stage I - Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue.

Blue iris key recovery