Welcome to Episode 84
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Tip of the Week– Staging Pressure Ulcers For Nurses
Bedsores, more properly known as pressure ulcers or decubitus ulcers, are lesions caused by many factors such as: unrelieved pressure; friction; humidity; shearing forces; temperature; age; continence and medication; to any part of the body, especially portions over bony or cartilaginous areas such as sacrum, elbows, knees, ankles etc.
Stage I is the most superficial, indicated by non-blanchable redness that does not subside after pressure is relieved. This stage is visually similar to reactive hyperemia seen in skin after prolonged application of pressure.
Stage II is damage to the epidermis extending into, but no deeper than, the dermis. In this stage, the ulcer may be referred to as a blister or abrasion.
Stage III involves the full thickness of the skin and may extend into the subcutaneous tissue layer. This layer has a relatively poor blood supply and can be difficult to heal.
Stage IV is the deepest, extending into the muscle, tendon or even bone.
Unstageable pressure ulcers are covered with dead cells, or eschar and wound exudate, so the depth cannot be determined.
Suspected Deep tissue injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Specific interventions depend on the stage of the pressure ulcer. Management includes wound care, debridement, and infection control.
Preventive measures comprise of turning or changing positions, skin care, early detection through proper risk assessment and more.
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“Wasting My Time” by Matthew Ebel
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