Question

Directions: For this assignment utilize your pressure ulcer staging guide and read the article entitled “Color Awareness: A Must for Patient Assessment”. Answer the following questions:

1. In your own words give a brief description of Stages I-IV and Unstage-able Pressure Injuries

2. In your own words describe a deep tissue injury

3. Name 3 risk factors for acquiring a pressure ulcer/pressure injury

4. Name 3 nursing interventions to prevent pressure ulcers/injuries or to prevent further damage of a current pressure ulcer/injury

What kinds of considerations should we think about when assessing for pressure injuries with a patient who has dark-skin/dark pigmentation of their skin

Answer 1

Ans.) A brief description of Stages I-IV and Unstage-able Pressure Injuries is given below -

Stage 1

Generally stage 1 is the mildest stage. These pressure sores only affect the upper layer of the skin. Its symptoms include pain, burning and itching . At first, the patients needs to stop the pressure on sores. It is recommended to wash the sore with mild soap and water. The pressure sore of stage 1 pressure sore go away in as little as 2 or 3 days.

Stage 2

In this stage the sore goes deeper below the surface of your skin. The common

Symptoms are broken skin which causes wound and looks like a pus-filled blister. In this stage the patient should clean the wound with warm water or a salt-water and dry it gently. Slowly the situation improves in 3 days to 3 weeks.

Stage 3

In the 3rd stage, the sores have enters in the fat tissue of the skin. Here, the sores look like a crater with a bad odor. In this stage, the patient needs more care. At the patient should consult to the doctor. He or may remove the dead tissue and give some antibiotics . This type of sore will take at least one month, and up to 4 months, to heal.

Stage 4

This is the most serious stage which affects the muscles and ligaments. Its sores are quite deep. Skin has turned black and filled with pus or drainage. In this case, the patient needs to immediately go to the doctor because these sores are needed immediate attention.These pressure sore could take anywhere from 3 months or much longer and in some serious cases it will take years to heal.

Risk factors for acquiring a pressure ulcer/pressure injury -

· Difficulty in movement - Patients who are unable to change their position are at greater risk of developing a pressure ulcer.

· Lack of proper nutritional – The patients with poor nutrition are at higher risk for the development of pressure ulcers.

· Change in skin color - Patients with darker skin pigmentation is at greater at risk for pressure ulcers than the lighter skin individual.

Nursing interventions to prevent pressure ulcers/injuries –

· Nurse help to change the patient’s position every two hours to stop ulcers from forming.

· Always place soft cushions between the bones and joints like ankles, wrists and other hard bone areas to prevent ulcers.

· Try to keep the skin dry and moisture free. Dry skin is less likely form pressure ulcers