, NR 224 Exam 2 Study Outline
The following is a list of concepts for you to understand to be successful on Exam 2
Skin
Pressure ulcers
o Stages – describe, identify
Category/Stage I: Nonblanchable Redness.
Intact skin presents with nonblanchable redness of a localized area, usually over a
bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain
may also be present. Darkly pigmented skin may not have visible blanching but
its coloring may differ from the surrounding area. The area may be painful, firm,
soft, warmer, or cooler compared to adjacent tissue. Category I may be difficult to
detect in individuals with dark skin tones. It may indicate “at risk” people
Category/Stage II: Partial-Thickness.
Partial thickness loss of dermis presents as a shallow, open ulcer with a red-pink
wound bed without slough. It may also present as an intact or open/ruptured
serum-filled or serosanguinous-filled blister. It presents as a shiny or dry shallow
ulcer without slough or bruising. The presence of bruising indicates deep tissue
injury. This category should not be used to describe skin tears, tape burns,
incontinence-associated dermatitis, maceration, or excoriation.
Category/Stage III: Full-Thickness Skin Loss.
In full-thickness tissue loss subcutaneous fat may be visible; but bone, tendon,
and muscle are not exposed. Slough may be present but does not obscure the
depth of tissue loss. It may include undermining and tunneling. The depth of a
category/stage III pressure ulcer varies by anatomical location. The bridge of the
nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and
category/stage III ulcers can be shallow. In contrast, areas of significant adiposity
can develop extremely deep category/stage III pressure ulcers. Bone/tendon is not
visible or directly palpable
Category/Stage IV: Full-Thickness Tissue Loss.
In full-thickness tissue loss with exposed bone, tendon, or muscle, subcutaneous
fat may be visible; but bone, tendon, and muscle are exposed. Slough or eschar
may be present. It often includes undermining and tunneling. The depth of a
category/stage IV pressure ulcer varies by anatomical location. The bridge of the
nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and
these ulcers can be shallow. Category/stage IV ulcers can extend into muscle
and/or supporting structures (e.g., fascia, tendon, or joint capsule), making
, osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly
palpable
Unstageable/Unclassified: Full-Thickness Skin or Tissue Loss—Depth
Unknown.
Full-thickness tissue loss in which actual depth of an ulcer is completely obscured
by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black)
in the wound bed is unstageable. Until enough slough and/or eschar are removed
to expose the base of a wound, the true depth cannot be determined; but it will be
either a category/stage III or IV. Stable (dry, adherent, intact without erythema or
fluctuance) eschar on the heels serves as “the natural (biological) cover of the
body” and should not be removed
Suspected Deep-Tissue Injury—Depth Unknown.
Suspected deep-tissue injury is a purple or maroon localized area of discolored
intact skin or a blood-filled blister caused by damage of underlying soft tissue
from pressure and/or shear. The area may be preceded by tissue that is painful,
firm, mushy, boggy, warmer, or cooler compared 1188to adjacent tissue. Deep-
tissue injury may be difficult to detect in individuals with dark skin tones. It may
begin as a thin blister over a dark wound bed. The wound may further evolve and
become covered by thin eschar. Evolution may be rapid, exposing additional
layers of tissue even with optimal treatment.
o Prevention – specific interventions
, Quick Guide to Pressure Ulcer Prevention
Risk Factor Nursing Interventions
Decreased sensory Provide pressure-redistribution surface. Be sure to include protection for
perception pressure points from medical devices such as oxygen tubing, feeding
tubes, and casts (Black et al., 2015; Fletcher, 2012).
Following each incontinent episode, clean area with no-rinse perineal
Moisture cleaner and protect skin with moisture-barrier ointment (Rolstad et al.,
2016).
Keep skin dry and free of maceration (Gray et al., 2011; Colwell et al.,
2011). Turn patient off of at-risk areas often.
Reposition patient using drawsheet or a transfer board surface.
Friction and shear Provide trapeze to facilitate movement in bed.
Position patient at a 30-degree lateral turn and limit head elevation to 30
degrees (see Figure 48-15).
Decreased Establish and post individualized turning schedule.
activity/mobility
Provide adequate nutritional and fluid intake; help with intake as necessary.
Poor nutrition Consult dietitian for nutritional assessment and recommended nutrients.
Prevention minimizes the impact that risk factors or contributing factors have on
pressure ulcer development. Three major areas of nursing interventions for
prevention of pressure ulcers are: (1) skin care and management of incontinence;
(2) mechanical loading and support devices, which include proper positioning and
the use of therapeutic surfaces; and (3) education (WOCN, 2010).
Topical Skin Care and Incontinence Management.
When you clean the skin, avoid soap and hot water. Use cleaners with nonionic
surfactants that are gentle to the skin. Many types of products are available for
skin care, and you need to match their use to the specific needs of the patient.
After you clean the skin and make sure that it is completely dry, apply moisturizer
to keep the epidermis well lubricated but not oversaturated.
Make an effort to control, contain, or correct incontinence, perspiration, or wound
drainage A moisture barrier protects the skin from excessive moisture and
bacteria found in the urine or stool.
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