Positioning

Question 1

What are some causes of skin breakdown?

Answer 1

• friction

- sheer

Question 2

What is a sign of skin breakdown?

Answer 2

• reddened areas that BLANCH when pressed

- blisters or ulcerations appear

Question 3

Pressure sore STAGE 1 means what?

Answer 3

• skin intact
• skin appears red and doesn’t lighten when touched
• site is painful, firm, soft, warmer, etc

Question 4

Pressure sore STAGE 2 means what?

Answer 4

• open wound
• outer layer and part of underlying layer is damaged/lost
• pressure ulcer may shallow, pinkish red, basin-like wound
• may be a fluid filled blister

Question 5

Pressure sore STAGE 3 means what?

Answer 5

• deep wound
• loss of skin exposes fat
• crater like appearance
• bottom of wound may have yellowish dead tissue

Question 6

Pressure sore STAGE 4 means what?

Answer 6

• large scale loss of tissue
• may expose bones, muscles, tendons
• crusty dead tissue

Question 7

What are some ways to provide pressure relief?

Answer 7

• turn every 2 hours
• keep back at 30* to bed
• float heels
• keep head at lowest possible angle