Pressure Ulcer Flashcards Preview

Remar Review > Pressure Ulcer > Flashcards

Flashcards in Pressure Ulcer Deck (11)
1

Stage 1pressure ulcers

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

2

What is an example of a stage 1 pressure ulcer?

Looks like a sunburn

3

Stage 2pressure ulcers

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

4

What are some examples of a stage 2 pressure ulcer?

Abrasion, blisters, shallow craters

5

Stage 3 pressure ulcers

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

6

What is an example of a stage 3 ulcer?

Deep crater

7

How would you describe a stage 3 pressure ulcer?

Skin is deeply damaged, does not extend through fascia

8

Stage IV pressure ulcers:

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

9

How would you describe a stage 4 pressure ulcer?

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

10

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

Proper ___ and _____


Turn pt q ___ hours


Keep skin ___ and ____;


Inspect ___ and ___

Proper diet and hydration

Turn pt q two hours

Keep skin clean and dry;


Inspect skin and document

11

5 nursing teaching point for pressure ulcers

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

Decks in Remar Review Class (169):