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pressure ulcer

a wound with a localized area of necrosis

factors to pressure ulcer formation

1. external pressure compresses blood vessels 2. friction and shearing forces injure vessels and abrade top skin layer

ischemia

deficiency of blood to tissue. caused usually by external pressure

hypoxia

inadequate oxygen to cells

necrosis

death of tissue

shear

when one layer of tissue slides over another

Risks for pressure ulcer development

immobility, nutrition, hydration, surface moisture, mental status, age.

Stage 1

A defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence.

Stage 2

Partial thickness loss

Stage 3

Full thickness loss, sub Q exposure, but not bone, tendon or muscle.

Stage 4

bone muscle tendon exposed.

Stage 5

Unstageable: can't see bed because of slough, eschar, or other.

Eschar

black leather scab of dead tissue

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