NR 224 Exam 2 Study Outline| Study Guide For A Grade Pass

Skin • Pressure ulcers o Stages – describe, identify Category/Stage I: Nonblanchable Redness. Intact skin presents with nonblanchable redness of a localized area, usually over abony 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 todetect 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- pinkwound 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 shallowulcer 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