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Factors that influence patient's personal hygiene?
social practices, body image, socioeconomic status, knowledge, personal preference, physical condition, and cultural variables
tissue layers of skin slide on each other causing subcutaneous blood vessels to kink or stretch and results in an interruption of blood flow to the skin
Patients at risk for pressure sores
are ill, debilitated, older, disabled, incontinent, and have spinal cord injuries, limited mobility or poor overall nutrition
Suspected deep tissue injury
localized purple or maroon area of intact skin or a blood-filled blister
Stage 2 pressure ulcer
partial thickness loss of dermis; shallow/open ulcer usually shiny or dry without slough or bruising
Stage 3 pressure ulcer
full thickness tissue loss in which subcutaneous fat is sometimes visible but bone, tendon, and muscle are not exposed
Stage 4 pressure ulcer
full thickness tissue loss with exposed bone, tendon, or muscle; often inlcudes undermining or tunneling
Unstageable pressure ulcer
full thickness tissue loss, a wound base cover by slough and/or eschar in the wound bed that will usually be tan, brown, or black
Patients at Risk for Oral Disorders
lack of knowledge about oral hygiene, inability to perform oral hygiene etc.
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