SOLVED693

Pressure Injury: Stage 2 Pathophysiology: Pressure Injury • Impaired skin integrity • Damaged tissue can result from skin and underlying tissue beneath bony prominences (elbows, heel of the foot, sacrum, knees etc.) are compressed against external surfaces for prolonged period • Restricts blood flow -> ischemia, inflammation, tissue necrosis • Stage 2: • Skin is not intact (ex. skin tear) • Exposed dermis • Wound bed: pink/red + moist • Intact or ruptured blister Subjective Data Objective Data 1. Patient states “I’d describe the pain as dull and throbbing” 2. Patient states “it feels like a burning pain above my buttocks” 3. Patient states “The area has been feeling warm in my sacral region” 4. Patient states “I can’t get to the bathroom so I have to wait until my wife gets home to help change me” 5. Patient states ” the pain has been consistent for 2 weeks” 1. Exposed dermis with partial-thickness skin loss in sacral region 2. Pink and moist wound bed 3. Warmth assessed on skin around sacral wound 4. Adipose and slough not visible 5. Wound is 2 inches in width and 1 inch length 2. • Prioritized Nursing Diagnosis • • Pain r/t tissue
SCIENCE
HEALTH SCIENCE
NURSING

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