Flashcards in Pressure Ulcer Deck (11)
Stage 1pressure ulcers
Stage I pressure ulcers: Skin intact, red, warm, painful. non-blanching
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,
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 muscle , bone or tendon,
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?
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