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13 terms

Pressure ulcers

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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