Pressure Ulcer Symptoms & Diagnosis

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Pressure Ulcer Symptoms & Diagnosis
Pressure Ulcer Symptoms & Diagnosis

Video: Pressure Ulcer Symptoms & Diagnosis

Video: Pressure Ulcer Symptoms & Diagnosis
Video: Pressure Ulcers (Injuries) Stages, Prevention, Assessment | Stage 1, 2, 3, 4 Unstageable NCLEX 2023, September
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Pressure ulcers: symptoms & diagnosis

In the case of pressure ulcers (bedsores), the symptoms (present symptoms) and the patient's history enable the diagnosis. The skin and tissue damage associated with a pressure sore can be seen with the naked eye (visual diagnosis). When developing, the pressure ulcer goes through different stages. The degree of severity depends on the extent to which the tissue has extended.

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Pressure ulcers are divided into four degrees of severity:

  • Grade I: Reddening that cannot be pushed away

    In the initial stage, reddening occurs which persists even after the pressure is removed. The reddened skin area does not become lighter even after brief pressure with a finger, but remains red ("finger pressure test"). A warming of the skin may be observed. However, the skin itself is still intact.

  • Grade II: Partial loss of the skin

    The superficial layers of the skin are already showing damage, for example a blister, a skin abrasion or a superficial wound.

  • Grade III: Loss of the skin

    All layers of the skin and large parts of the connective tissue lying under the skin are destroyed. A deep wound forms. However, muscle and bone tissues are still intact.

  • Grade IV: complete loss of skin or tissue.

    The wound is so deep that muscle tissue and bones are exposed. Tissue death (necrosis) occurs.

Note A pressure sore is a major burden for those affected and is often associated with severe pain.

How is the diagnosis made?

First, the pressure ulcer is carefully examined. Factors such as the location, stage and size of the pressure ulcer, possible pocket formation, recording of the wound healing phase, wound edges and wound environment are recorded. For a precise assessment, the doctor asks questions about the medical history (anamnesis).

The following factors, among others, are collected:

  • Underlying disease,
  • individual pressure ulcer risk,
  • Nutritional status,
  • Taking medication,
  • Possible disruptive factors in wound healing: e.g. skin blood flow, dead tissue, wound infection, poor overall condition of the person affected,
  • existing pain.

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