Exam 2 Flashcards
Identify those patients who are at risk for pressure ulcers.
- lack of sensory perception,
- compromised nutrition (malnutrition = body need increased protein to heal, malnutrition hinders protein levels. Check albumin/prealbumin),
- constant exposure to moisture,
- lack of physical activity/immobility (especially bed-bound),
- friction and shear. Even something as simple as bumping an elbow on a bed rail can lead to a pressure ulcer in an immunocompromised or nutritionally deficient pt.
- Advanced age,
- incontinence,
- infection (resistance to bacterial infection decreased by compressed skin. Tissue necrosis may hasten infection process.)
- Low BP
Stage I Pressure Ulcer
- Intact skin with non-blanchable erythema
- Usually over bony prominence
- May be tender upon palpation. Tenderness might be only indication in people with a dark complexion.
- The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Stage II pressure ulcer
Partial thickness loss
May present as:
-A shallow open ulcer with a red pink wound bed, without slough.
-A blister
-A shiny or dry shallow ulcer without slough or bruising
Keep these “moist like your eyeball with normal saline, unless it’s a blister.”
Don’t pop the blister!
Stage III pressure ulcer
Full thickness tissue loss
Subcutaneous fat may be visible but bone, tendon or muscle are not exposed nor are they directly palpable.
May include:
slough
tunneling
undermining
Depth may vary according to location (bony bridge of nose vs fatty coccyx)
Stage IV pressure ulcer
Full thickness tissue loss
Contains exposed bone, tendon, or muscle
Slough or eschar may be present
Often includes undermining and/or tunneling
Depth may vary according to location (bony bridge of nose vs fatty coccyx)
Bone, tendon, or muscle directly visible or palpable
Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur.
