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12 Cards in this Set
- Front
- Back
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A ? ulcer develops in the hospital.
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Nosocomial
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Pressure ulcer development is caused by ?(MMAFINE)
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Moisture, Mental status, Age,Friction/Shearing, Immobility, Nutrition/Hydration, External pressure.
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A ? wound is about 3 months in duration.
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chronic
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Prior to stage 1 Pressure Ulcers there is a ? that is a blanchable redness.
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Hyperemia
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Name the level of the pressure ulcer: intact skin with non blanchable redness of a localized area usually over a bony prominence.
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Stage 1
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Name the stage of the pressure ulcer: Partial thickness loss of dermis presenting as ashallow open ulcer with a red pink wound bed, usually without slough.
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Stage 2
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Name the stage of the pressure ulcer:Full thickness tissue loss. Subcutaneous fat may be visible but, tendon or muscle are not exposed. Slough may be present but doesn't obscure the depth of tissue loss, May include undermining and tunneling.
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Stage 3
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? is dead tissue that is yellow in color.
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Slough
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Name the stage of the pressure ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or exchar may be present on some parts of the wound bed. Often includes undermining and tunneling.
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Stage 4
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Name the stage of the pressure ulcer: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, so we can't really see the underlying wound.
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Unstageable
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Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear is suspected to be a ?
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Deep Tissue Injury
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Name a possible Nsg Dx for pressure ulcers?
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Impaired skin integrity related to the effects of pressure of immobility secondary to fatigue. AEB stage 1 pressure ulcer on coccyx.
or Impaired tissue integrity related to decreased blood and nutrients to tissues secondary to surgical AEB abdominal surgical incision. |
