NR I224 IExam I2 IStudy IOutline
Skin
• Pressure Iulcers
o Stages I– Idescribe, Iidentify
Category/Stage II: INonblanchable IRedness.
Intact I skin Ipresents I with I nonblanchable Iredness Iof Ia I localized Iarea, I usually Iover
IaIbony Iprominence. IDiscoloration Iof Ithe I skin, I warmth, Iedema, Ihardness, Ior Ipain
I may Ialso Ibe Ipresent. IDarkly Ipigmented I skin I may I not I have I visible Iblanching Ibut
I its Icoloring I may Idiffer I from I the Isurrounding Iarea. IThe Iarea I may Ibe Ipainful, I firm,
Isoft, Iwarmer, Ior Icooler Icompared Ito Iadjacent Itissue. ICategory II I may Ibe Idifficult
ItoIdetect I in I individuals Iwith Idark Iskin Itones. IIt I may I indicate I “at Irisk” Ipeople
Category/Stage III: IPartial-Thickness.
Partial Ithickness I loss Iof Idermis Ipresents Ias Ia Ishallow, Iopen I ulcer Iwith Ia Ired-
pinkIwound Ibed Iwithout Islough. I It I may Ialso Ipresent Ias Ian I intact Ior Iopen/ruptured
Iserum- filled Ior Iserosanguinous-filled Iblister. IIt Ipresents Ias Ia Ishiny Ior Idry
IshallowIulcer Iwithout I slough Ior Ibruising. IThe Ipresence Iof Ibruising I indicates Ideep
Itissue I injury. I This Icategory Ishould I not Ibe I used I to Idescribe Iskin I tears, Itape Iburns,
I incontinence-associated Idermatitis, I maceration, Ior Iexcoriation.
Category/Stage IIII: IFull-Thickness ISkin ILoss.
In I full-thickness I tissue I loss Isubcutaneous I fat I may Ibe I visible; Ibut Ibone, I tendon,
Iand I muscle Iare I not Iexposed. ISlough I may Ibe Ipresent Ibut Idoes I not Iobscure Ithe
Idepth Iof Itissue I loss. IIt I may I include I undermining Iand Itunneling. I The Idepth Iof Ia
Icategory/stage IIII Ipressure I ulcer I varies Iby Ianatomical I location. I The Ibridge Iof Ithe
Inose, Iear, Iocciput, Iand I malleolus Ido I not I have I(adipose) Isubcutaneous Itissue; Iand
Icategory/stage IIII I ulcers Ican Ibe Ishallow. IIn Icontrast, Iareas Iof Isignificant
IadiposityIcan Idevelop Iextremely Ideep Icategory/stage IIII Ipressure I ulcers.
IBone/tendon I is I notIvisible Ior Idirectly Ipalpable
Category/Stage IIV: IFull-Thickness ITissue ILoss.
In I full-thickness I tissue I loss Iwith Iexposed Ibone, I tendon, Ior I muscle, Isubcutaneous
I fat I may Ibe I visible; Ibut Ibone, Itendon, Iand I muscle Iare Iexposed. ISlough Ior Ieschar
I may Ibe Ipresent. IIt Ioften I includes I undermining Iand I tunneling. IThe Idepth Iof Ia
Icategory/stage IIV Ipressure I ulcer I varies Iby Ianatomical I location. I The Ibridge Iof Ithe
Inose, Iear, Iocciput, Iand I malleolus Ido I not I have I(adipose) Isubcutaneous Itissue; Iand
Ithese I ulcers Ican Ibe I shallow. ICategory/stage IIV I ulcers Ican Iextend I into I muscle
Iand/or Isupporting I structures I(e.g., I fascia, I tendon, Ior Ijoint Icapsule), I making
Iosteomyelitis Ior Iosteitis I likely Ito Ioccur. I Exposed Ibone/muscle I is I visible Ior
IdirectlyIpalpable
Unstageable/Unclassified: IFull-Thickness ISkin IorITissue ILoss—Depth
Unknown.
, Full- thickness Itissue I loss I in I which Iactual Idepth Iof Ian I ulcer I is Icompletely
IobscuredIb y Islough I(yellow, I tan, I gray, I green Ior Ibrown) Iand/or Ieschar I(tan, Ibrown
Ior Iblack) I in Ithe I wound Ibed I is I unstageable. IUntil Ienough Islough Iand/or Ieschar Iare
Iremoved I to Iexpose Ithe Ibase Iof Ia Iwound, I the Itrue Idepth Icannot Ibe Idetermined; Ibut
I it I will Ibe Ieither Ia Icategory/stage IIII Ior IIV. IStable I (dry, Iadherent, I intact I without
Ierythema Ior I fluctuance) Ieschar Ion Ithe I heels Iserves Ias I “the Inatural I(biological)
Icover Iof Ithe Ibody” I and Ishould I not Ibe Iremoved
Suspected IDeep-Tissue IInjury—Depth IUnknown.
Suspected Ideep-tissue I injury I is Ia Ipurple Ior I maroon I localized Iarea Iof Idiscolored
I intact Iskin Ior Ia Iblood- filled Iblister Icaused Iby Idamage Iof I underlying I soft I tissue
I from Ipressure Iand/or I shear. I The Iarea I may Ibe Ipreceded Iby I tissue Ithat I is Ipainful,
I firm, I mushy, Iboggy, I warmer, Ior Icooler Icompared I1188to Iadjacent Itissue. I Deep-
Itissue I injury I may Ibe Idifficult Ito Idetect I in I individuals Iwith Idark Iskin Itones. IIt
I mayIbegin Ias Ia Ithin Iblister Iover Ia Idark Iwound Ibed. IThe Iwound I may I further Ievolve
IandIbecome Icovered Iby I thin Ieschar. I Evolution I may Ibe I rapid, Iexposing Iadditional
I layers Iof Itissue Ieven I with Ioptimal I treatment.
o I Prevention I– Ispecific Iinterventions
Quick IGuide Ito IPressure IUlcerIPrevention
, Risk IFactor Nursing IInte rventions
Decreased Provide Ipressure-redistribution Isurface. IBe Isure Ito I include
IsensoryIpercep IprotectionIfor Ipressure Ipoints I from I medical Idevices Isuch Ias
tion Ioxygen I tubing, I feeding Itubes, Iand Icasts I(Black Iet Ial., I2015;
IFletcher, I2012).
Following Ieach I incontinent Iepisode, Iclean Iarea Iwith Ino-rinse
IperinealIc leaner Iand Iprotect Iskin Iwith I moisture-barrier Iointment
Moisture
I(Rolstad I et Ial., I2016).
Keep Iskin Idry Iand I free Iof I maceration I(Gray Iet Ial., I2011;
IColwellIet Ial., I2011). ITurn Ipatient Ioff Iof Iat-risk Iareas Ioften.
Reposition Ipatient Iusing Idrawsheet Ior Ia Itransfer Iboard
Isurface.IP rovide Itrapeze Ito I facilitate I movement I in Ibed.
Friction Iand Ishear
Position Ipatient Iat Ia I30-degree I lateral I turn Iand I limit I head Ielevation
ItoI30 Idegrees I(see IFigure I48-15).
Decreased Establish Iand Ipost I individualized Iturning Ischedule.
activity/mobility
Provide Iadequate I nutritional Iand I fluid I intake; I help Iwith I intake
IasInecessary.
Poor Inutrition
Consult Idietitian Ifor Inutritional Iassessment Iand
IrecommendedInutrients.
Prevention I minimizes Ithe I impact Ithat Irisk I factors Ior Icontributing I factors I have
IonIp ressure Iulcer Idevelopment. I Three I major Iareas Iof I nursing I interventions I for
Iprevention Iof Ipressure Iulcers Iare: I(1) Iskin Icare Iand I management Iof I incontinence;
(2) I mechanical I loading I and Isupport Idevices, Iwhich I include Iproper Ipositioning
IandIthe I use Iof Itherapeutic Isurfaces; Iand I(3) Ieducation I(WOCN, I2010).
Topical ISkin ICare Iand IIncontinence IManagement.
When I you Iclean Ithe Iskin, Iavoid Isoap Iand I hot Iwater. I Use Icleaners I with I nonionic
Isurfactants Ithat Iare I gentle Ito I the Iskin. IMany Itypes Iof Iproducts Iare Iavailable I for
Iskin Icare, Iand Iyou I need Ito I match Itheir I use I to Ithe Ispecific I needs Iof I the Ipatient.
IAfter I you Iclean Ithe Iskin Iand I make Isure Ithat I it I is Icompletely Idry, Iapply
ImoisturizerIto Ikeep I the Iepidermis I well I lubricated Ibut I not Ioversaturated.
Make Ian Ieffort Ito Icontrol, Icontain, Ior Icorrect I incontinence, Iperspiration, Ior I wound
drainage IA I moisture Ibarrier Iprotects Ithe Iskin I from Iexcessive I moisture Iand
IbacteriaIfound I in I the I urine Ior Istool.
Skin
• Pressure Iulcers
o Stages I– Idescribe, Iidentify
Category/Stage II: INonblanchable IRedness.
Intact I skin Ipresents I with I nonblanchable Iredness Iof Ia I localized Iarea, I usually Iover
IaIbony Iprominence. IDiscoloration Iof Ithe I skin, I warmth, Iedema, Ihardness, Ior Ipain
I may Ialso Ibe Ipresent. IDarkly Ipigmented I skin I may I not I have I visible Iblanching Ibut
I its Icoloring I may Idiffer I from I the Isurrounding Iarea. IThe Iarea I may Ibe Ipainful, I firm,
Isoft, Iwarmer, Ior Icooler Icompared Ito Iadjacent Itissue. ICategory II I may Ibe Idifficult
ItoIdetect I in I individuals Iwith Idark Iskin Itones. IIt I may I indicate I “at Irisk” Ipeople
Category/Stage III: IPartial-Thickness.
Partial Ithickness I loss Iof Idermis Ipresents Ias Ia Ishallow, Iopen I ulcer Iwith Ia Ired-
pinkIwound Ibed Iwithout Islough. I It I may Ialso Ipresent Ias Ian I intact Ior Iopen/ruptured
Iserum- filled Ior Iserosanguinous-filled Iblister. IIt Ipresents Ias Ia Ishiny Ior Idry
IshallowIulcer Iwithout I slough Ior Ibruising. IThe Ipresence Iof Ibruising I indicates Ideep
Itissue I injury. I This Icategory Ishould I not Ibe I used I to Idescribe Iskin I tears, Itape Iburns,
I incontinence-associated Idermatitis, I maceration, Ior Iexcoriation.
Category/Stage IIII: IFull-Thickness ISkin ILoss.
In I full-thickness I tissue I loss Isubcutaneous I fat I may Ibe I visible; Ibut Ibone, I tendon,
Iand I muscle Iare I not Iexposed. ISlough I may Ibe Ipresent Ibut Idoes I not Iobscure Ithe
Idepth Iof Itissue I loss. IIt I may I include I undermining Iand Itunneling. I The Idepth Iof Ia
Icategory/stage IIII Ipressure I ulcer I varies Iby Ianatomical I location. I The Ibridge Iof Ithe
Inose, Iear, Iocciput, Iand I malleolus Ido I not I have I(adipose) Isubcutaneous Itissue; Iand
Icategory/stage IIII I ulcers Ican Ibe Ishallow. IIn Icontrast, Iareas Iof Isignificant
IadiposityIcan Idevelop Iextremely Ideep Icategory/stage IIII Ipressure I ulcers.
IBone/tendon I is I notIvisible Ior Idirectly Ipalpable
Category/Stage IIV: IFull-Thickness ITissue ILoss.
In I full-thickness I tissue I loss Iwith Iexposed Ibone, I tendon, Ior I muscle, Isubcutaneous
I fat I may Ibe I visible; Ibut Ibone, Itendon, Iand I muscle Iare Iexposed. ISlough Ior Ieschar
I may Ibe Ipresent. IIt Ioften I includes I undermining Iand I tunneling. IThe Idepth Iof Ia
Icategory/stage IIV Ipressure I ulcer I varies Iby Ianatomical I location. I The Ibridge Iof Ithe
Inose, Iear, Iocciput, Iand I malleolus Ido I not I have I(adipose) Isubcutaneous Itissue; Iand
Ithese I ulcers Ican Ibe I shallow. ICategory/stage IIV I ulcers Ican Iextend I into I muscle
Iand/or Isupporting I structures I(e.g., I fascia, I tendon, Ior Ijoint Icapsule), I making
Iosteomyelitis Ior Iosteitis I likely Ito Ioccur. I Exposed Ibone/muscle I is I visible Ior
IdirectlyIpalpable
Unstageable/Unclassified: IFull-Thickness ISkin IorITissue ILoss—Depth
Unknown.
, Full- thickness Itissue I loss I in I which Iactual Idepth Iof Ian I ulcer I is Icompletely
IobscuredIb y Islough I(yellow, I tan, I gray, I green Ior Ibrown) Iand/or Ieschar I(tan, Ibrown
Ior Iblack) I in Ithe I wound Ibed I is I unstageable. IUntil Ienough Islough Iand/or Ieschar Iare
Iremoved I to Iexpose Ithe Ibase Iof Ia Iwound, I the Itrue Idepth Icannot Ibe Idetermined; Ibut
I it I will Ibe Ieither Ia Icategory/stage IIII Ior IIV. IStable I (dry, Iadherent, I intact I without
Ierythema Ior I fluctuance) Ieschar Ion Ithe I heels Iserves Ias I “the Inatural I(biological)
Icover Iof Ithe Ibody” I and Ishould I not Ibe Iremoved
Suspected IDeep-Tissue IInjury—Depth IUnknown.
Suspected Ideep-tissue I injury I is Ia Ipurple Ior I maroon I localized Iarea Iof Idiscolored
I intact Iskin Ior Ia Iblood- filled Iblister Icaused Iby Idamage Iof I underlying I soft I tissue
I from Ipressure Iand/or I shear. I The Iarea I may Ibe Ipreceded Iby I tissue Ithat I is Ipainful,
I firm, I mushy, Iboggy, I warmer, Ior Icooler Icompared I1188to Iadjacent Itissue. I Deep-
Itissue I injury I may Ibe Idifficult Ito Idetect I in I individuals Iwith Idark Iskin Itones. IIt
I mayIbegin Ias Ia Ithin Iblister Iover Ia Idark Iwound Ibed. IThe Iwound I may I further Ievolve
IandIbecome Icovered Iby I thin Ieschar. I Evolution I may Ibe I rapid, Iexposing Iadditional
I layers Iof Itissue Ieven I with Ioptimal I treatment.
o I Prevention I– Ispecific Iinterventions
Quick IGuide Ito IPressure IUlcerIPrevention
, Risk IFactor Nursing IInte rventions
Decreased Provide Ipressure-redistribution Isurface. IBe Isure Ito I include
IsensoryIpercep IprotectionIfor Ipressure Ipoints I from I medical Idevices Isuch Ias
tion Ioxygen I tubing, I feeding Itubes, Iand Icasts I(Black Iet Ial., I2015;
IFletcher, I2012).
Following Ieach I incontinent Iepisode, Iclean Iarea Iwith Ino-rinse
IperinealIc leaner Iand Iprotect Iskin Iwith I moisture-barrier Iointment
Moisture
I(Rolstad I et Ial., I2016).
Keep Iskin Idry Iand I free Iof I maceration I(Gray Iet Ial., I2011;
IColwellIet Ial., I2011). ITurn Ipatient Ioff Iof Iat-risk Iareas Ioften.
Reposition Ipatient Iusing Idrawsheet Ior Ia Itransfer Iboard
Isurface.IP rovide Itrapeze Ito I facilitate I movement I in Ibed.
Friction Iand Ishear
Position Ipatient Iat Ia I30-degree I lateral I turn Iand I limit I head Ielevation
ItoI30 Idegrees I(see IFigure I48-15).
Decreased Establish Iand Ipost I individualized Iturning Ischedule.
activity/mobility
Provide Iadequate I nutritional Iand I fluid I intake; I help Iwith I intake
IasInecessary.
Poor Inutrition
Consult Idietitian Ifor Inutritional Iassessment Iand
IrecommendedInutrients.
Prevention I minimizes Ithe I impact Ithat Irisk I factors Ior Icontributing I factors I have
IonIp ressure Iulcer Idevelopment. I Three I major Iareas Iof I nursing I interventions I for
Iprevention Iof Ipressure Iulcers Iare: I(1) Iskin Icare Iand I management Iof I incontinence;
(2) I mechanical I loading I and Isupport Idevices, Iwhich I include Iproper Ipositioning
IandIthe I use Iof Itherapeutic Isurfaces; Iand I(3) Ieducation I(WOCN, I2010).
Topical ISkin ICare Iand IIncontinence IManagement.
When I you Iclean Ithe Iskin, Iavoid Isoap Iand I hot Iwater. I Use Icleaners I with I nonionic
Isurfactants Ithat Iare I gentle Ito I the Iskin. IMany Itypes Iof Iproducts Iare Iavailable I for
Iskin Icare, Iand Iyou I need Ito I match Itheir I use I to Ithe Ispecific I needs Iof I the Ipatient.
IAfter I you Iclean Ithe Iskin Iand I make Isure Ithat I it I is Icompletely Idry, Iapply
ImoisturizerIto Ikeep I the Iepidermis I well I lubricated Ibut I not Ioversaturated.
Make Ian Ieffort Ito Icontrol, Icontain, Ior Icorrect I incontinence, Iperspiration, Ior I wound
drainage IA I moisture Ibarrier Iprotects Ithe Iskin I from Iexcessive I moisture Iand
IbacteriaIfound I in I the I urine Ior Istool.
