Week 10 - Staging Pressure Ulcers Flashcards
1
Q
What do stage 1 pressure ulcers look like? (2)
A
- Epidermis is intact
- Erythema not resolved within 30 minutes of pressure relief
- Reversible with intervention
2
Q
What do stage 2 pressure ulcers look like? (6)
A
- Partial-thickness loss of skin layers involving epidermis
- possibly penetrating into but not through dermis
- May have blistering with redness or induration
- Wound base most and pink
- Painful
- free of necrotic tissue
3
Q
What do stage 3 pressure ulcers look like? (4)
A
- Full-thickness tissue loss extending through dermis to subcut tissue
- Shallow crater unless covered by eschar
- may have necrotic tissue, exudate or infection
- Wound base is usually not painful
4
Q
What do stage 4 pressure ulcers look like? (4)
A
- deep tissue destruction extending through subcut tissue to fascia
- Possible involving muscle, joint or bone
- May include necrotic tissue, exudate, infection
- Wound base is usually not painful
5
Q
What is an unstageable pressure ulcer? (3)
A
- covered by eschar or slough, preventing the visualization of the wound bed
- Unable to accurately stage
- Depth unknown
6
Q
What is a deep tissue pressure injury?
A
- A localized area of purple or maroon discoloured intact skin
7
Q
What are some characteristics of a deep tissue pressure injury? (2)
A
- A blood filled blister due to damage of underlying soft tissue from pressure and/or shear
- An area which is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue
8
Q
Which interdisciplinary health team members can you consult for pressure ulcers? (4)
A
- OT
- PT
- Dietician
- Clinical nurse specialist
9
Q
What do effective interventions for pressure injuries lead to? (4)
A
- Maintenance of intact and healthy skin
- Reduced risk for skin cancer
- Absence of pressure injuries
- Positive self-esteem
10
Q
How can we apply the CJMM to treat pressure ulcers? (4)
A
- Recognize changes in the skin
- Recognize risks for reduced skin integrity
- Intervention to treat pressure injury
- Intervention to decrease risk
How do we know if what has been done is effective?
