Pressure Ulcer Prevention and Staging
Pressure ulcers result from sustained pressure over bony prominences. Nurses prevent them through repositioning, skin care, and risk assessment.
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What you must know about Pressure Ulcer Prevention
Pressure ulcers commonly occur over bony prominences (sacrum, heels, hips, elbows).
Reposition immobile patients at least every 2 hours to relieve pressure.
Use risk assessment tools such as the Braden or Waterlow scale.
Stage 1 is non-blanchable erythema of intact skin; stage 4 involves full-thickness loss exposing bone/muscle.
Keep skin clean and dry; manage moisture and incontinence promptly.
Ensure adequate nutrition and hydration to support skin integrity.
NMCN Exam Tips
How this topic appears in the NMCN exam
Repositioning every 2 hours is the classic prevention answer.
Sacrum and heels are the most common ulcer sites.
Stage 1 = intact skin with non-blanchable redness.
Braden/Waterlow scales assess pressure ulcer risk.
Practice Question
Test yourself
The MOST effective nursing measure to prevent pressure ulcers in an immobile patient is to:
Explanation
Regular repositioning (at least every 2 hours) relieves sustained pressure over bony prominences and is the cornerstone of pressure ulcer prevention. Vigorous massage of reddened areas is discouraged as it can damage fragile tissue.
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