Flashcards in Pressure Ulcer Deck (11):
Stage 1pressure ulcers
Stage I pressure ulcers: Skin intact, red, non-blanching, warm, painful
What is an example of a stage 1 pressure ulcer?
Looks like a sunburn
Stage 2pressure ulcers
Stage II pressure ulcers: Skin is not intact, loss of the dermis occurs, pink/red, open wound, shallowness
What are some examples of a stage 2 pressure ulcer?
Abrasion, blisters, shallow craters
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.
What is an example of a stage 3 ulcer?
How would you describe a stage 3 pressure ulcer?
Skin is deeply damaged, does not extend through fascia
Stage IV pressure ulcers:
Stage IV pressure ulcers: Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling
How would you describe a stage 4 pressure ulcer?
Skin is deeply damage, wound shows muscles, tissues and ligaments
What are some nursing interventions to prevent pressure ulcers from developing?
Turn pt q ___ hours
Keep skin ___ and ____;
Inspect ___ and ___
Proper ___ and _____
Turn pt q two hours
Keep skin clean and dry;
Inspect skin and document
Proper diet and hydration