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, non-blanching, warm, painful

2

Stage 2pressure ulcers

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

3

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.

4

Stage IV pressure ulcers:

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

5

What are some examples of a stage 2 pressure ulcer?

Abrasion, blisters, shallow craters

6

How would you describe a stage 3 pressure ulcer?

Skin is deeply damaged, does not extend through fascia

7

What is an example of a stage 3 ulcer?

Deep crater

8

How would you describe a stage 4 pressure ulcer?

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

9

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

Turn pt q two hours

Keep skin clean and dry;


Inspect skin and document


Proper diet and hydration

10

What is an example of a stage 1 pressure ulcer?

Looks like a sunburn

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

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