Pressure Ulcer

Question 1

Stage 1pressure ulcers

Answer 1

Stage I pressure ulcers: Skin intact, red, warm, painful. non-blanching

Question 2

What is an example of a stage 1 pressure ulcer?

Answer 2

Looks like a sunburn

Question 3

Stage 2pressure ulcers

Answer 3

Stage II pressure ulcers: 
Skin is not intact, 
loss of the dermis occurs, 
open wound, 
shallowness , 
pink/red,

Question 4

What are some examples of a stage 2 pressure ulcer?

Answer 4

Abrasion, blisters, shallow craters

Question 5

Stage 3 pressure ulcers

Answer 5

Stage III pressure ulcers:
Full thickness skin loss,
extends into the dermis and subcutaneous tissue.
Slough and tunneling may be present.

Question 6

What is an example of a stage 3 ulcer?

Answer 6

Deep crater

Question 7

How would you describe a stage 3 pressure ulcer?

Answer 7

Skin is deeply damaged, does not extend through fascia

Question 8

Stage IV pressure ulcers:

Answer 8

Stage IV pressure ulcers: Full thickness skin loss,
exposed muscle , bone or tendon,
slough or eschar, and tunneling

Question 9

How would you describe a stage 4 pressure ulcer?

Answer 9

Skin is deeply damage, wound shows muscles, tissues and ligaments

Question 10

What are some nursing interventions to prevent pressure ulcers from developing?

Proper ___ and _____

Turn pt q ___ hours

Keep skin ___ and ____;

Inspect ___ and ___

Answer 10

Proper diet and hydration

Turn pt q two hours

Keep skin clean and dry;

Inspect skin and document

Question 11

5 nursing teaching point for pressure ulcers

Answer 11

1.) frequently change positions every two hours
2.)never give a hot bath or use hot water on a patient with a dermal pressure ulcer
3.)use pillows for support and The head of bed should be raise at least 30°
4.) we lift we don’t pull
5.) never massage over only bony province
Given to me 2000ml of fluid a day