Term
| pathophysiology of pressure ulcers |
|
Definition
| vascular compromise, tissue anoxia, and cell death |
|
|
Term
| (new) pressure ulcer stages |
|
Definition
(Suspected) Deep Tissue Injury,
Stage I, II, III, IV and
U (unstageable)
|
|
|
Term
|
Definition
Intact skin with non-blanchable redness of a localized area usually over a bony prominence
usually cooler, or warmer to touch |
|
|
Term
|
Definition
|
Partial thickness loss of dermis presenting as a shiny, dry, shallow open ulcer with a red pink wound bed, without slough
|
|
|
Term
|
Definition
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present,May include undermining and tunneling
|
|
|
Term
|
Definition
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
|
|
|
Term
| unstageable pressure ulcer |
|
Definition
Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
dont know the depth, severity or stage until the eschar is removed.
|
|
|
Term
| suspected deep tissue injury |
|
Definition
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.
tissue that is painful, firm, mushy, boggy, warmer or cooler |
|
|
Term
|
Definition
#1 relieve the pressure
#2 Turn, turn, turn
#3 specialty beds
#4 topical wound care |
|
|
Term
|
Definition
-Topical skin care:
skin, dry and clean
use moisture barrier creams
absorbent chux
-Positioning
hob at least 30degrees
reposition pt every 2 hours
use postioning devices
limit sitting in chairs to 2 hours |
|
|
