Risk Factors for Pressure Ulcer Development
When patients are unable to feel when a part of their body undergo increased, prolonged pressure or pain.
What is altered sensory perception?
Non-blanchable erythema of intact skin
What is stage 1?
Escaped blood loss from a blood vessel.
What is hemorrhage?
This lab level determines the best nutritional status of a patient.
What is pre-albumin?
Perform this when you initiate care and a minimal of once per shift. It is the foundation for developing a care plan.
What is a skin assessment?
The force that occurs in the opposite direction from the intended movement. It often occurs when the head of the bed of greater than 60 degrees.
What is shear?
Partial-thickness skin loss with exposed dermis
What is Stage 2?
Caused by microorganisms that invade tissue and prolongs the inflammatory phase that can lead to tissue destruction .
What is infection?
This determines of adequate amounts of oxygenated blood is circulating.
What is tissue perfusion?
This is revealed from the assessment clusters of data.
What is nursing diagnosis?
This happens when skin is dragged across bed linen aka sheet burn.
What is friction?
Full-thickness skin loss
What is Stage 3?
Partial or total separation of previously approximated wound edges of a surgical site.
What is dehiscence?
Adequate amounts of proteins, vitamins, and minerals.
What is nutrition?
This is developed to promote interventions. Critical thinking ensures this integrates all you know about the patient and key elements.
What is plan of care?
The state of patients who are comatose, confused, or disoriented.
What is alteration in LOC?
Full-thickness skin and tissue loss
What is stage 4?
Protrusion of visceral organs through a surgical incision.
What is evisceration?
The physiological change that slows all phases of wound healing.
What is aging?
Prompt identification of patients at high risk for pressure injuries or for impaired wound healing requires timely and appropriate _______ and require a holistic approach that uses interprofessional expertise such as wound care specialists.
What are intervention/implementations?
Patients who are unable to independently change positions.
What is impaired mobility?
Obscured full-thickness skin and tissue loss.
What is unstageable?
Negative factors that slow the healing process.
What is diabetes?
What is smoking?
Factors such as body image changes, self-concept, and sexuality on wound healing.
What is psychosocial impact?
You ______ the effectiveness of nursing interventions for reducing and treating pressure injuries and other wounds by determining the patient's response to nursing therapies, determining outcomes, and ______ whether he or she achieved each goal
What is evaluate?