Fundamentals of Nursing
Pressure Injury Staging
Pressure injuries are localized areas of tissue necrosis caused by unrelieved pressure.
Staging Classification
- Stage 1: Intact skin, non-blanchable redness.
- Stage 2: Partial-thickness skin loss with exposed dermis.
- Stage 3: Full-thickness skin loss, adipose tissue visible.
- Stage 4: Full-thickness skin and tissue loss, muscle/bone visible.
- Unstageable: Obscured by slough or eschar.
Nursing Interventions
- Reposition patient every 2 hours.
- Use pressure-reducing surfaces and pillows.
- Maintain skin cleanliness and dryness.
- Assess nutritional status, specifically protein intake.
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