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Pressure Ulcer? - ✔✔localized injury to the skin and/or underlying tissue
usually over a bony prominence, as a result of pressure, or pressure in
combination with shear.
Pressure - ✔✔the force per unit surface area that is applied vertically or
perpendicular to the surface of the skin. It deforms underlying tissue and
compresses small blood vessels hindering blood flow and nutrient supply.
Tissues become ischemic and are damaged or die.
ischemic - ✔✔Disruption of the blood supply due to an obstruction,
usually a thrombus or embolism, that causes infarction of brain tissue
Shear - ✔✔the force per unit surface area applied parallel to the skin
surface. It occurs when one layer of tissue slides horizontally over another,
deforming adipose and muscle tissue, and disrupting blood flow.
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,classification system for pressure ulcers - ✔✔includes four numerical
categories/stages with two additional categories/stages for use in the
United States.
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Suspected Deep Tissue Injury
Category/Stage I Pressure Ulcer - ✔✔-Intact skin with non-blanchable
redness (erythema) of a localized area usually over a bony prominence.
-Darkly pigmented skin may not have visible blanching; its color may
differ from the surrounding area.
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, -The area may be painful, firm, soft, warmer, or cooler as compared to
adjacent tissue.
-may be difficult to detect in individuals with dark skin tones.
May indicate "at risk" persons.
Blanchable - ✔✔apply fingertip and slight pressure to red area; if skin turn
a lighter shade of of red or whitish color,injury is not severe
NonBlanchable Erythema - ✔✔a defined area of redness that persists (does
not blanch/become pale) when pressure is applied to the area.
Category/Stage II Pressure Ulcer - ✔✔-Partial thickness loss of dermis
presenting as a shallow open ulcer with a red pink wound bed, without
slough.
-may also present as an intact or open/ruptured serum-filled or
serosangineous-filled blister.
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