NURSE-UN 240 Study Guide - Midterm Guide: Pressure Ulcer, Hyperaemia, Risk Assessment
10 Nov 2018
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Identify patients at risk for the development of pressure injuries (decubiti, Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Epibole (rolled edges), undermining and/or tunneling often occur. (d) if slough or eschar obscures the extent of tissue loss this is an. Pain and temperature change often precede skin color changes. Granulation tissue is also very fragile and prone to easy injury. Granulation tissue is shiny red and granular in appearance when it is healthy; when inadequate blood flow exists, granulation tissue may pale in color. Before applying heat or cold therapies, assess a patient"s physical condition for signs of potential intolerance to heat and cold: first observe the area to be treated. Sensitivity to pain and may not perceive any pain associated with heat or cold applications: open wounds, broken skin, stomas (1) subcutaneous and visceral tissues are more sensitive to temperature variations.
