NCLEX EXAM CHEAT SHEET FOR STAGING A PRESSURE ULCER FINAL ASSESSMENT
STAGING A PRESSURE ULCER Definition Staging Prevention Common Locations Individuals who spend long periods of time in bed or seated in a wheelchair are most at risk. Pressure ulcers most often affect the tissue over bony parts of the body, such as those illustrated here: • Encourage or assist with position changes, at least every 1–2 hours. • Avoid prolonged moisture; protect skin from urine, stool or wound drainage if present. • Utilize specialized mattresses, pads or cushions to relieve and redistribute pressure. • Maintain tissue integrity with a well balanced, protein-rich diet. Always do a full head-to-toe skin assessment upon admission or transfer to your unit, and document appropriately. Pressure ulcers are injuries to the skin and underlying tissue caused by prolonged pressure, which restricts blood flow. Toes Pressure of bone against hard surface Friction of skin against hard
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