Chp. 36. pgs. 922-924
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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
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
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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