Test 2/pressure Sores

Front 1

HOW ARE PRESSURE SORES PREVENTED

Back 1

CHECK RES PRONE TO PRESSURE ULCERS ONCE A DAY OR MORE VIA CARE PLAN

PREVENT PRESSURE, CHANGE POSITION AT LEAST EVERY 2 HOURS OR MORE VIA CARE PLAN

TURNING SHOULD BE SCHEDULED FOR RES WHO IS HELPLESS

USE ANTIPRESSURE DEVICES (AIR MATTRESS, PILLOWS, WATERBED, HEEL AND ELBOW PROTECTORS.

PROMOTE GOOD CIRCULATION WITH ROM

PROMOTE GOOD SKIN CONDITION, CLEAN AND DRY

PREVENT FRICTION ON THE RES' SKIN BY KEEPING BED WRINKLE FREE AND SMOOTH, USING A LIFT SHEET OT LIFT RES, AVOID MASSAGE OVER BONY PROMINENCES.

Front 2

STAGE 1 PRESSURE ULCERS

Back 2

STAGE 1: MAY BE SUPERFICIAL OR A SIGN OF DEEPER TISSUE DAMAGE, NONBLANCHABLE REDNESS OF SKIN, WARMTH , REDNESS OR SWELLING. MAY BE DIFFICULT TO ASSESS, IF PRESSURE IS REDUCED OR REMOVED STATE 1 PRESSURE ULCER CAN BE PREVENTED.

Front 3

DOCUMENTATION, OBSERVATIONS AND REPORTING

Back 3

OBSERVATIONS: LOCATION OF PRESSURE ULCER, CONDITION OF THE SKIN, SKIN TEMPERATURE, SIZE, DRAINAGE PRESENT, ODOR.

REPORT TO CHARGE NURSE IF DRESSING BECOMES SOILED OR DISLODGED.

DOCUMENT, CARE GIVEN, TIME GIVEN, AND SIDE TO WHICH RES WAS TURNED.

Front 4

POSITIONING TO PREVENT SHEARING

Back 4

PLACE A LIFT OR TRANSFER SHEET UNDER PATIENT TO MOVE OR REPOSITION RES TO PREVENT SHEARING OR FRICTION TO THE RES' SKIN.

Front 5

STAGE 2 PRESSURE ULCERS

Back 5

PARTIAL THICKNESS SKIN LOSS INVOLVING THE EPIDERMIS, DERMIS, OR BOTH

MAY APPEAR AS A BLISTER, ABRASION OR SHALLOW CRATER

Front 6

STAGE 3 PRESSURE ULCERS

Back 6

FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO OR NECROSIS OF SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO, BUT NOT THROUGH, UNDERLYING FASCIA (MUSCLE OR BONE)

Front 7

STAGE 4 PRESSURE ULCERS

Back 7

FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION; TISSUE NECROSIS; DAMAGE TO MUSCLE, BONE, TENDONS, OR JOINTS.

MAY INCLUDE UNDERMINING OR SINUS TRACTS (TUNNELLING)

DEAD (NECROTIC) TISSUE MAY BE SEEN IN STAGES 3 AND 4. DYING TISSUE MAY APPEAR BLACK, BROWN, GREY OR YELLOW AND MAY BE EITHER MOIST OR DRY.