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Pressure sores sore - Coggle Diagram
Pressure sores
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Definition
Also known as pressure ulcers are localized skin injury where tissues are compressed between bony prominences and hard surfaces such as a mattress.
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Nursing managent
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Assessment
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Assess the client’s nutritional status, including weight, weight loss, and serum albumin levels, if indicated.
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Stages
Stage 2:Partial-thickness skin loss involving epidermis, dermis, or both.
Stage 3: Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
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Stage 4:Extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures, with or without full-thickness skin loss.
Unstageable: Full-thickness tissue loss in which actual depth of ulcer is completely obstructed by slough or eschar in the wound bed.
Pathophysiology
Necrosis and ulceration where soft tissues are compressed between bony prominences and external hard surfaces.
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References
Andersen KE, Jensen O, Kvorning SA, Bach E. Prevention of pressure sores by identifying patients at risk. BMJ. 1982;284(6326):1370–1371
Bale S, Tebble N, Jones V, Price P. The benefits of implementing a new skin care protocol in nursing homes. Journal of Tissue Viability. 2004;14(2):44–50