HOW - Wound/Ostomy Related Documents
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Transcript HOW - Wound/Ostomy Related Documents
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The staging system currently
recommended by AHRQ (AHCPR),
NPUAP and WOCN (and accepted
by Medicare) is a six-stage system
based on the tissue layers
involved
LOOK FAMILIAR?
NOW YOU KNOW
WHY THERE WAS
A REASON YOU
MEMORISED THIS
Stage I
Defined area of non-blanchable
erythema of INTACT skin (vs.
reactive hyperemia) usually over
a bony prominence. Pigmented
skin may not have visible
blanching; its color may differ from
surrounding area.The area may be
painful, firm, soft (boggy) warmer
or cooler than adjacent tissue.
(NOT eschar)
Take home
Words?
Intact
Non-blanchable
Non-necrotic
Boggy
And think…..?pressure point?
7/21/2015
Reactive Hyperemia
is the red skin color that is normally
observed once pressure to an area has
been relieved. This type of hyperemia is
blanchable and will resolve in
approximately 1/2 to 3/4 the amount of
time that the area was exposed to
pressure. (Increased blood supply to
clear away byproducts of ischemia) e.g.
a patient who is repositioned Q 2H may
experience this over a bony prominence
for as long as 11/2 hours following the
position change.
Reactive Hyperemia
Stand up: look at your fingers,
your neighbor’s crossed ankles ,
a leaned-upon elbow, and if you
ask very politely, posterior thigh
at chair edge
This is a normal process and
should not be misclassified as a
Stage I pressure ulcer.
Deep Tissue Injury
Manifested as deep red, maroon,
purple tissue or blood-filled blister.
Epidermis may or may not be
intact and usually sloughs off.
Usually results from
pressure/shear
NOT to be confused with Stage I
CAUTION
Be careful about charting “red
sacrum” : Is it
Hyperemia?
Stage I?
Scar?
Deep Tissue Injury?