The document discusses pressure ulcers, including defining them as lesions caused by unrelieved pressure that damage underlying tissue. It describes the pathology of pressure ulcers as resulting from pressure, blood vessel collapse, and tissue necrosis. It also lists factors that affect development of pressure ulcers such as aging, immobility, nutrition, hydration, moisture, warmth, poor hygiene, and incontinence. The document provides steps for preventing pressure ulcers, which include identifying at-risk patients, assessing skin daily, keeping skin clean and dry, avoiding massage over bony areas, minimizing friction, improving nutrition and mobility, and documenting prevention measures used.
7. FRICTION AND SHEARING FORCES
Friction-two surfaces
rub against each
other
Shearing-one layer of
tissue slide over
another
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10. PRESSURE ULCER STAGING
STAGE I - Nonblanching
Erythema With Skin Intact.
STAGE II - Partial Thickness Skin
Loss(epidermis)- Blister / Abrasion
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11. PRESSURE ULCER STAGING
STAGE III – Fullthickness Skin Loss -
Necrosis Of Hypodermic Tissue
STAGE IV - Fullthickness Skin Loss -
Extensive Damage To Muscle,boneor
Supporting Structures
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23. ACTION
Assist the patient to the prone
position or side – lying position with
the back exposed from the shoulders
to the sacral area.
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24. RATIONALE
This position exposes an
adequate area for massage with
privacy and warmth maintained
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25. ACTION
Use the bath blanket to drape the
patient. Raise the bed to the high
position and lower the side rail closest
to you.
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26. RATIONALE
. Having the bed in the high
position reduces back strain for
the nurse.
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27. ACTION
Warm the lubricant or lotion in the
palm of your hand or place the
container in warm water.
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32. ACTION
Place your hands beside each other
at the base of the patient’s spine and
stroke upward to the shoulders and
back downward to the buttocks in
slow, continous strokes. Continue for
several minutes.
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34. ACTION
Massage the patient’s shoulders, entire
back, areas over iliac crests, and sacrum
with circular stroking motion. Keep your
hands in contact with the patient’s skin.
Continue for several minutes, applying
additional lotion as necessary.
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41. ACTION
During massage, observe the
patient’s skin for reddened or
open areas. Pay particular
attention to the skin over bony
prominences.
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42. RATIONALE
Pressure may interfere with
circulation and lead to
development of decubitus ulcers.
Back rub stimulates circulation to
these areas.
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43. ACTION
Use the towel to pat the patient
dry and to remove excess lotion.
Apply powder if the patient
requests it.
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