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7 terms

Decubitus Ulcers

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Stage 1
Redness, edema, superficial epidermis and dermis involved.
Stage 2
Redness, edema, blistering and hardening (induration) of tissue, skin is open and inflammation extends to the fat layer with superficial necrosis in advanced stage II lesions.
Stage 3
A full thickness skin lesion extending down to the muscle, the ulcer margin is thickened.
Stage 4
Ulcer extends down to the bone and includes bone destruction.
Intervention:
Prevention is the most effective intervention:
• Use wheelchair cushions, floatation pads, and pressure-relief bed aids to distribute pressure over a large skin surface.
• Train the individual and/or caregivers in positioning and weight-shifting techniques and schedules and in proper skin care.
weight-shifting techniques
1. Full push-ups, lateral leans, forward leans, or wheelchair tilt/recline options are common techniques used depending upon the abilities of the individual.
2. Weight shifts should occur every 30 min for 30 sec
Train in proper skin care
- keep skin free of excessive moisture, dryness, and heat
- check skin a least two timer per day for any evidence of breakdown.