After turning a bedridden client from her side to her back, the nurse observes that the area over the trochanter is red and does not blanch with finger pressure. The nurse should document this observation as:
A)
a stage I pressure ulcer.
B)
ischemia.
C)
eschar.
D)
hyperemia.
A
Explanation:
A)
Nonblanchable erythema with intact skin is characteristic of a stage 1 pressure ulcer. Ischemia indicates lack of blood flow, and erythema is not present. Eschar indicates dead necrotic tissue. Hyperemia is redness from increased blood flow to a site which resolves when pressure is removed.
Application
Implementation
Safe, Effective Care Environment: Coordinated Care
B)
Nonblanchable erythema with intact skin is characteristic of a stage 1 pressure ulcer. Ischemia indicates lack of blood flow, and erythema is not present. Eschar indicates dead necrotic tissue. Hyperemia is redness from increased blood flow to a site which resolves when pressure is removed.
Application
Implementation
Safe, Effective Care Environment: Coordinated Care
C)
Nonblanchable erythema with intact skin is characteristic of a stage 1 pressure ulcer. Ischemia indicates lack of blood flow, and erythema is not present. Eschar indicates dead necrotic tissue. Hyperemia is redness from increased blood flow to a site which resolves when pressure is removed.
Application
Implementation
Safe, Effective Care Environment: Coordinated Care
D)
Nonblanchable erythema with intact skin is characteristic of a stage 1 pressure ulcer. Ischemia indicates lack of blood flow, and erythema is not present. Eschar indicates dead necrotic tissue. Hyperemia is redness from increased blood flow to a site which resolves when pressure is removed.
Application
Implementation
Safe, Effective Care Environment: Coordinated Care
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