Pressure Ulcers
suspected deep tissue injury is...
a purple or maroon area of intact skin or blood filled blister
an avoidable pressure ulcer is...
am ulcer that develops from the improper use of the nursing process
why are avoidable pressure ulcers preventable?
if you use the nursing process correctly the risk for ulcers are low
what 2 things may signal an infection?
pain and delayed healing
how do you prevent friction in bed?
powder the patient's sheets lightly
the 5 stages of pressure ulcers are...
stage 1. color does not fade with pressure -blue, purple or pale color in skin stage 2. wound may involve a blister or shallow ulcer stage 3. the skin is gone, subcutaneous fat may be exposed stage 4. slough & eschar (pieces of dead tissue that is cast off the surface of the skin) may be present stage 5. Unstageable: full thickness tissue loss with the ulcer covered by slough and eschar
what are the 6 stages of pressure ulcers?
1. Intact skin with redness over a bony prominence 2. partial thickness skin loss 3. full thickness tissue loss 4. full thickness tissue loss with muscke, tendon and bone exposure 5. full thickness tissue loss with ulcer covered by slough or eschar 6. suspected deep tissue injury
what are 4 key pressure ulcer prevention measures for persons at risk?
1. managing moisture 2. good nutrition 3. fluid balance 4 relieving pressure
pressure ulcers usually occur over bony areas because...
the bony areas bear the body's weight in certain positions
stage one pressure ulcer
the color does not fade with pressure, skin color may differ from surrounding areas which may appear purple, pale, or blue
older and disabled persons are more at risk for pressure ulcers because...
their skin is fragile and easily injured
what is a shear?
when layers of the skin rub against each other
pressure Ulcers usually occur...
where medical devices touch the skin
