NCLEX-PN

●​ Pressure : Eliminate pressure using frequent repositioning, pressure-relieving surfaces, and encouraging mobility. ●​ Friction : Minimize friction by ensuring proper positioning and lifting techniques. ●​ Shearing: Reduce shearing forces by proper elevation of the head of the bed and using appropriate transfer techniques. Pressure Ulcer Staging ●​ Stage I : Intact skin with redness or blanching. For darker skin tones, blue or purple hues may be present. ●​ Stage II : Open skin with damage to epidermis and dermis, appearing as blister, crack, or pink wound. ●​ Stage III : A deep wound involving subcutaneous tissue and deeper layers, potentially exposing adipose tissue. ●​ Stage IV : A deep ulcer extending into muscles, fascia, tendons, and even bone, exhibiting necrotic tissue. ●​ Unstageable : The base of the wound is covered by dead tissue ○​ Slough : Debris that appears tan, yellow, green, or brown in color. ○​ Eschar : a hard plaque that’s tan, brown, or black in color. Your doctor can only determine how deep the wound is after clearing it out. If there’s extensive tissue damage, it will need to be surgically removed. Suspected deep tissue injuries can be deceptive because, on the surface, they may seem like Stage 1 or 2 ulcers, but they have the potential to progress to deeper, more severe wounds (Stage 3 or 4). These injuries are often characterized by a purplish or maroon discoloration, and they might be mistaken for blood blisters or covered with eschar (a thick, black, necrotic tissue).

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