90%(105)95 out of 105 people found this document helpful
This preview shows page 15 - 18 out of 21 pages.
A nurse is teaching a group of nursing students about the National Pressure Ulcer Advisory Panel’s classification system for pressure ulcers.RELATED CONTENT: List the six pressure ulcer stages along with a brief description of the assessment
appear blue or purple in darker skin tones. 3.STAGE II: This stage of pressure ulcer is characterized by shallow open ulcer with a red pink wound bed. It can also present as an intact or open/ruptured serum-filled blister. At this stage, there is a partial-thickness loss of dermis and the ulcer can appear as shiny or dry shallow slough. The ulcer at this stage may become infected, possibly with pain and scant drainage.4.STAGE III: At this stage, the subcutaneous fat may be open, but the bone, tendon, or muscle are not exposed. This stage presents with a full-thickness tissue loss. This stage of pressure ulcer can look shallow in areaswhere there is no subcutaneous fat like the ear and nose. It’s depth usually depends on the anatomical location. Slough may be present but will not obscure the depth of tissue loss. The areas that are rich in subcutaneous tissue experience a deep and big damage to the subcutaneous tissue. Drainage and infection of the wound can occur at this stage.5.STAGE IV: Unlike in stage III, bone, muscle, and tendon are exposed with full thickness tissue loss and tissue necrosis. This stage makes Osteomyelitis possible because the ulcer extends into the muscle and other supporting structures like tendon and fascia. There may be slough, eschar, tunneling, undermining, and infection.6.UNSTAGEABLE: At this stage, the base of the ulcer is obscured by slough (can be yellow, tan, grey, green, or brown) and eschar (can be tan, brown, or black). The stage of the ulcer cannot be determined until the slough and eschar is removed to reveal the base of the wound. NURSING ACTIONS: List four nursing interventions to help prevent pressure ulcers. Reposition clients every 2 hours while in bed and every 1 hour while sitting on a chair. This will help to relieve pressure on the bony prominences where pressure ulcer mostly occur.Use pressure-relieving devices and implement pressure reduction surfaces like air mattress, foam mattress. Keep clients clean, dry, well-nourished, and hydrated.If possible, encourage ambulation and mobility of clients.TREATMENT OPTIONS: List two treatment options for pressure ulcers