Chp. 36. pgs. 922-924

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  1. Four stages of pressure ulsers
    Stage 1-  nonblanchable erythema signaling potential breakdown.

    Stage II- partial thickness, skin loss, (abrasion, blister or shallow crater involving epidermis & possibly the dermis.

    Stage III- Full-thickness skin loss involving damage or necrosis that may extend down to, but not through underlying fasia.

    Stage IV- full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures such as tendon or joint capsule
  2. Types of Wound Healing
    1. Primary intention healing-occurs when the tissue surfaces have been approximated(closed) and there is minimal or no tissue loss.

    2. Secondary intention healing- wound that is extensive & involves considerable tissue loss
  3. Braden Scale for Pressure Sore Risk
    Sensory perception-ability to respond meaningfully to pressure-related discomfort.

    Moisture-degree to which skin is exposed to moisture

    Activity- degree of physical activity

    Mobility- ability to change & control body position.

    Nutrition- usual food intake pattern

    • Friction & Shear- 
    • Adult who scores >18 is considered at risk. Total of 23 pts is possible.
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Chp. 36. pgs. 922-924
2013-02-22 01:54:40
Skin Integrity Wound Care

Exam 3
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