Pressure Ulcer Flashcards Preview

Remar Review > Pressure Ulcer > Flashcards

Flashcards in Pressure Ulcer Deck (11)
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1
Q

Stage 1pressure ulcers

A

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

2
Q

What is an example of a stage 1 pressure ulcer?

A

Looks like a sunburn

3
Q

Stage 2pressure ulcers

A
Stage II pressure ulcers: 
Skin is not intact, 
loss of the dermis occurs, 
open wound, 
shallowness , 
pink/red,
4
Q

What are some examples of a stage 2 pressure ulcer?

A

Abrasion, blisters, shallow craters

5
Q

Stage 3 pressure ulcers

A

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

6
Q

What is an example of a stage 3 ulcer?

A

Deep crater

7
Q

How would you describe a stage 3 pressure ulcer?

A

Skin is deeply damaged, does not extend through fascia

8
Q

Stage IV pressure ulcers:

A

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

9
Q

How would you describe a stage 4 pressure ulcer?

A

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

10
Q

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

Proper ___ and _____

Turn pt q ___ hours

Keep skin ___ and ____;

Inspect ___ and ___

A

Proper diet and hydration

Turn pt q two hours

Keep skin clean and dry;

Inspect skin and document

11
Q

5 nursing teaching point for pressure ulcers

A

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

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