1. Fall Prevention
a. In Homes:
i. Remove items that could cause the client to trip(throw rugs and loose carpets)
ii. Place electrical cords and
... [Show More] extension cords against a wall behind furniture
iii. Monitor gait and balance, and provide aids as needed
iv. Make sure that steps and sidewalks are in good repair
Place grab bars near the toilet and in the tub or shower and install a stool riser
Fall Prevention
In Hospitals
i. Fall bracelets and yellow socks
ii. Bed alarm
iii. Remove clutter
iv. Keep items within reach(call light, personal items)
v. Gait Belts
vi. "Call, don't fall"
1. Orient them to the call light and educate them to use call light to get help rather than getting up without assistance. Nurses should respond to call light in a timely manner
vii. Put them in room close to nurses station
viii. Have good lighting (especially at night)
ix. BEDS:
1. Put in low position
2. Lock wheels
3. Use side rails appropriately
1. Home Safety
a. Preschoolers and School Age Children
i. Firearms
1. Keep firearms unloaded, locked up, and out of reach
2. Teach to never touch a gun or stay at a friend's house where a gun is accessible
3. Store bullets in a different locations from guns
1. Home Safety
a. Preschoolers and School Age Children
i. Poison
1. Teach child about the hazards of alcohol, cigarettes, and prescription, non-prescription, and illicit drugs
2. Keep potentially dangerous substances out of reach
Have the poison control hotline number available
1. Home Safety
a. Preschoolers and School Age Children
i. Motor Vehicles
1. Use booster seats for children who are less than 4ft 9in tall and weigh less than 40lbs(usually 4 to 8 years old)
2. If the care has a passenger air bag, place children under 12 yrs in the back seat
3. Use seatbelts properly after booster seats are no longer necessary
4. Use protective equipment when participating in sports, riding a bike, or riding as passenger on a bike
5. Supervise and teach safe use of equipment
6. Teach the child to play in safe areas and never run after a ball or toy that goes into a road
7. Teach child safety rules of the road.
a. Look both ways before crossing road
a. Fire Safety
i. Elements of Home Safety Plan
1. Where the exit plan in
2. Oxygen safety measures
3. Fire extinguishers and everyone knows there location
Smoke detectors need batteries checked every 6 mos
1. Center of Gravity
a. should be close to the base of support (below the umbilicus at the top of the pelvis)
b. spread feet, wide base of support
c. hold objects close to you
Bathing
a. Bathe clients to cleanse the body, stimulate circulation, provide relaxation, and enhance healing.
b. Bathing clients is often delegated to the assistive personnel. However, the nurse is responsible for data collection and client care
c. Bathe clients whose health problems have exhausted them or limited their mobility.
i. Give a complete bath to clients who can tolerate it and who hygiene needs warrant it
ii. Allow rest periods for clients who become tired during bathing
iii. Partial baths are useful when clients cannot tolerate a complete bath, need particular, cleansing of odorous or uncomfortable areas, or can perform part of the bath independently.
iv. Therapeutic baths are used to promote comfort and provide treatment (soothing itchy skin)
Bed Bath:
i. Ensure privacy
ii. Start with face then arms and chest, then go to legs and feet, and then finally perineal.
iii. Encourage patient to participate:
1. Wash their face and perineal area
2. usually set up the washcloth for them and allow them to do what they can and help with what they can't allowing them the independence they still have. "we'll work together"
3. Brush their own teeth
Foot Care
a. Prevents skin breakdown, pain, and infection
b. Is extremely important for clients with diabetes mellitus and a qualified professional must perform it.
c. Scrub between toes
d. Don't clip nails but file if needed.
e. Check for sores, signs of cyanosis, and skin breakdown
1. Pain Assessment
a.P:provoking/relieving; what makes it worse and better
b. Q: quality; how the pain feels: throbbing, aching, burning
c. R: radiate; does the pain radiate anywhere else
d. S: severity; on a scale of 1 to 10 how much does it hurt
T: timing; onset, duration, and frequency
1. Pain Medication Administration
a. Asses before giving pain meds:
i. PQRST
ii. Possible drug interactions, allergies
iii. Correct orders
iv. Correct dosage and medications
1. Pain Medication Administration (PT.2)
a. Analgesics are the mainstay for relieving pain. The three classes of analgesics are non-opioids, opioids and adjuvants
i. Concerns when taking Opioids:
1. Lower BP and HR
a. Orthostatic hypotension (fall risk)
2. Constipation
3. Urinary retention
4. Respiratory depression
a. S&S
i. Bradypnea, RR less than 8 per min, and are shallow
Low O2 saturation
Pain Medication Administration (PT.3)
a. Before giving more pain medications reassess vitals (look at quality of respirations) and another pain assessment
Pain Medication Administration (PT.4)
a. After giving medication:
i. Reevaluate pain level in:
1. IV: 30 min
2. Oral: 1 hour
ii. Check vitals
b. The parenteral route is best for immediate, short-term relief of acute pain
The oral route is better for chronic, non-fluctuating pain
1. Culture
a. Is what people in a group have in common and it changes over time.
a. Can be adopted by assimilation
b. Effect on healthcare:
i. What treatments they accept
ii. How they view healthcare
iii. How they view illness/disease/health/pain
iv. How often or when they access health care
v. Death rituals
Time Orientation
a. some cultures tend to be past, present, or future oriented
b. may be late to appointments because their culture (don't wear watches)
c. they value traditions and relationships over time and deadlines
they might not take medications on time
1. Health Disparities (pg. 302)
a. Health Status
i. Higher rates of illness and death in minority groups
ii. African American: higher maternal death rates
Health Disparities (pg. 302
a. Quality of Care
Blacks receive worse care compared to white
Health Disparities (pg. 302
a. Access to Care
Lack of access to preventative healthcare and language barriers can account for differences in the health status of racial and ethnic groups
SBAR Communication
a. S: situation
b. B: background
c. A: assessment
d. R: recommendations
1. Body Mechanics
a. Body Alignment
i. Places the spine in a neutral (resting) position.
ii. Allows the bones to be aligned, reduces stress and fatigue, & muscles, joints, and ligaments can work efficiently.
Body Mechanics
When lifting something:
i. Keep feet apart
ii. Lift with legs, not back
iii. Keep it close to you
Don't have bed in lower position, stand close to the bed, angle the body toward direction your moving the patient to(avoid twisting
Body Mechanics
Balance
i. Line of gravity should pass through the center of gravity ( imaginary vertical line drawn from the head through the center gravity.)
ii. Gravity of center should be close to the base of support (below the umbilicus at the top of the pelvis)
iii. Base of support is what holds your body up (feet)
iv. The body is balanced when your line of gravity must pass through your center of gravity, and your center of gravity must be close to your base of support
Body Mechanics
Coordination
i. Smooth movements require coordination between nervous system and musculoskeletal system.
ii. Voluntary movements are initiated in the cerebral cortex.
iii. Damage the motor cortex, cerebellum, or basal ganglia affects coordination of movements.
iv. Cerebral Cortex = Voluntary Movement
v. Cerebellum = Coordination (proprioception = awareness of posture, movement and position sense).
vi. Basal Ganglia = Helps with Coordination
1. Posture
a. Tips to maintain posture
i. Avoid standing in one position for a lengthy period. If you cannot change position, place one foot on a stool or box and alternate
ii. Do not lock knees when standing upright
iii. Keep your stomach muscles tight to support your back
iv. Do not bend forward at the waist or neck when are working in a low position
v. When you are seated, work at a comfortable height
vi. Do not wear high-heeled or platform shoes from ling periods of time
vii. Do not slump when you sit
viii. Sit close to your work
ix. Use a chair that supports your back in a slightly arched position
x. Sit with your feet flat on the floor and your knees below your hips
Sleep on a mattress that is firm but not extremely hard
Benefits of Mobility on Respiratory System
a. Improves pulmonary circulation
b. Improves gas exchange at alveolar capillary membrane
c. Dilates bronchioles to increase ventilation
Reduces risk of pneumonia
1. Benefits of Regular Exercise
a. Cardiovascular System
i. Improves pumping action of heart
ii. Decreases HR and BP
iii. Improves circulation by increasing the number of capillaries
Improves venous return to the heart
1. Benefits of Regular Exercise Respiratory System
i. Improves pulmonary circulation
ii. Improves gas exchange at alveolar capillary membrane
iii. Dilates bronchioles to increase ventilation
1. Benefits of Regular
a. Musculoskeletal System
i. Increase muscles mass, strength, power and endurance
ii. Improves flexibility
iii. Increases coordination
iv. Helps maintain joint structure
v. Improves gait speed, stability and balance
vi. Reduces risk of falls and helps older adults maintain independent lifestyle
vii. Improves bone mass and density
viii. Improves skeletal development in children
1. Benefits of Regular
a. Nervous System
i. Speeds nerve impulse transmission
ii. Reduces sympathetic response to exercise
iii. Improves reaction time
1. Benefits of Regular
a. Endocrine System
i. Increases sensitivity to insulin at the receptor site
ii. Increases efficiency of metabolic process
Improves temperature regulation
1. Benefits of Regular
a. GI System
i. Improves appetite
ii. Improves abdominal muscle tone
iii. Decreases risk of colon cancer
iv. Walking increases peristalsis
1. Benefits of Regular
a. Urinary System
i. Increases efficiency of kidney function
1. Benefits of Regular
a. Integumentary System
Improves skin tone as a result of improved circulation
1. Benefits of Regular
Immune system
i. Reduces susceptibility to minor viral illnesses
ii. Reduces systemic inflammation
1. Benefits of Regular
a. Mental Health
i. Boosts energy level
ii. Release endorphins, which assist with pain control and stress management
iii. Improves self-esteem and body image
iv. Promotes clearer thinking and improved memory in older adults
v. Provides nonpharmacological management to symptoms of anxiety and depression
1. Benefits of Regular
a. Overall Health
i. Burns calories to achieve and maintain healthy body weight
ii. Leads to reduced abdominal obesity
iii. Improves overall stamina
iv. Reduces fatigue
Increases sleep time and improves sleep quality.
Fowler's
i. Semi sitting position in which the head of the bed is elevated 45 to 60 degrees.
ii. This position promotes respiratory function by lowering the diaphragm and allowing the greatest chest expansion.
iii. Semi-Fowler's: head is raised 30-45 degrees
iv. High-Fowler's: the head is raised 60-90 degrees (recommended for patient who have trouble breathing)
Lateral
i. Side-lying position with the top hip and knee flexed and placed in front of the rest of the body.
ii. Creates pressure on the lower scapula, ilium, and trochanter but relieves pressure from heels and sacrum
Sims
i. Semi-prone position
ii. The lower arm is positioned behind the patient, and the upper arm is flexed.
iii. This position facilitates drainage from the mouth and limits pressure on the trochanter and sacrum
Supine
i. Also known as the dorsal recumbent position
ii. The patient lies on their back with head and shoulders elevated on a small pillow.
iii. Used for those with Hypotension
a. Prone
i. The patient lies on their abdomen with their head turned to one side.
This is the only position that allows full extension of the hips and knees. It also allows secretions to drain from the mouth
a. Tri-pod (orthopneic)
Used for patients with COP
Trendelenburg
i. Head down, feet up
ii. Helps with venous return
iii. Used for those with Hypotension
How to move patient up in bed:
i. use another person's help
ii. use draw sheet(can cause shearing), it is even better to use plastic device
iii. patient should have hands across their chest, so they don't have shearing on the arms, with the patient supine, and head lifted towards chest(reduces risk of hyperextension).
1. Range of Motion Terms
Extension
movement that increases the angle between two adjacent bones
Circumduction
a conical movement of a body part. (rolling your neck, head in a circle)
Adduction
movement of an extremity toward the midline of the body
Abduction
movement of an extremity away from the midline of the body
Internal rotation
rotating a joint inward
External rotation
rotating a joint outward
Flexion
movement that decreases the angle between two adjacent bones
Active ROM
i. Patient does not need assistance with ROM
Passive ROM
Anytime someone is assisting someone with ROM
Interventions to Prevent Risk for Contractures
a. Passive ROM
i. Flexion and extension
1. DVT
Signs and Symptoms
i. Unilateral pain
ii. Swelling
iii. Warmth
iv. Redness
v. Assessment:
Measure the calf!!!
1. DVT
a. Prevention
i. Calf pump exercises
ii. If appropriate: get patient walking once an hour
iii. SCD: sequential compression devices
iv. Changing their position
1. DVT
a. Risk Factors
i. Immobility (venous stasis)
ii. Obesity
iii. Cancer or chemo
iv. Diabetes
v. History of smoking or current smoker
vi. Oral contraceptives
vii. Older adults (especially with hip fractures)
viii. Heart disease
ix. Surgical procedure longer than 30 minutes
1. Adaptive Devices
We use them to promote client independence as much as possible
Interventions to Promote Respiratory Function
a. Positioning (High-Fowler's for meals to reduce risk of aspiration)
b. Incentive spirometer (take deep breaths)
c. Deep breathing techniques
d. Coughing
Chain of Infection
i. Infectious Agent
ii. Reservoir (ex. soil, water, animals)
iii. Mode of Transmission
iv. Portal of Entry
v. Portal of Exit
vi. Susceptible host
1. Chain of Infection
a. Interventions to interrupt
i. WASH HANDS
ii. PPE- breaks the chain before portal of entry
1. Nosocomial Infection
a. Hospital-acquired infections
b. Ex. iatrogenic, C. Diff, MRSA, pneumonia, UTI
a. Humoral Immunity
i. "antibody-mediated"
ii. Protects the body by circulating antibodies to fight against pathogens.
iii. The body produces leukocytes that seek out and destroy pathogens
Cellular Immunity
i. "Cell-mediated"
ii. Response acts directly to destroy pathogens without using antibodies but rather by activating phagocytes and T&B cells
Innate
i. Born with it
a. Acquired
Acquired through interaction between microbes, virus, fungus, etc
Transmission based precautions
Types and PPE used
i. Droplet:
1. Infection travels in water droplets expelled as in infected person exhales, coughs, sneezes or talks
2. Used for: influenza, pertussis
3. PPE worn: gloves, gown, surgical mask
1. Transmission based precautions
a. Types and PPE used
Airborne
1. For pathogens that are very small and remain infectious over long distances when suspended in the air; and easily transmitted through air currents
2. Used for: TB
3.PPE worn: N95, negative airflow room, goggles, gown, gloves
1. Transmission based precautions
a. Types and PPE used
Contact
1. For organisms spready by direct contact with the patient or his environment. This is the most common form of transmission
2. Used for: MRSA
3. PPE worn: gown and gloves
Virulence
Its power to cause disease
Antibiotics
a. Bacterial infections
b. Helps with inflammation
Risk Factors for Infection
a. Open wound
b.Immunocompromised or on immunosuppressant
Interventions to Prevent Infection
a. Hand hygiene
b. PPE
c. Not putting anything that is contaminated in contact with clothing, skin and other objects
1. Osteoporosis/Osteoarthritis
a. Risk Reduction
i. Weight bearing activities
ii. Stop smoking and drinking
iii. Calcium- supplements and calcium rich foods
iv. Control weight
Reduce caffeine
Plantar Fasciitis
a. Inflammation of the fascia located in the arch of the foot.
b. Obesity is a contributing factor
c. Severe pain in the arch of the foot especially when getting out of bed.
d. Respond to conservative management
i. Rest
ii. Ice
iii. Stretching exercises
iv. Maintaining the arch of the foot
v. Shoes with good support
vi. Orthotics
vii. NSAIDS or steroids
Endoscopic surgery to remove the inflamed tissue
Hallux Valgus
a. Bunions
b. foot deformity where great toe drifts laterally
Factors to contribute to musculoskeletal trauma
a. Inadequate nutrition
b. Osteoporosis
c. Age
Complete:
bone is fully divided
Incomplete
bone is not fully divided
Open
bone extends through the skin
Closed
: does not extend through the skin
Displaced
bone breaks into two or more pieces and moves out of alignment.
Fractures
a. Priority Assessments
i. Comfort/Pain level
ii. Loss of function
iii. Bleeding (internal and external)
iv. Check circulation:
1. Pulses
2. Capillary refill
3. Bruising
4. Edema
Loading Force
The force required to fracture a bone in a compression fracture
Cast Care
-Handle with the palms of your hands
-Have patient report painful "hot spots" under the cast which might indicate area of pressure necrosis
-Instruct the patient to never put anything down into the cast i.e. pencil.
-Don't get it wet
-Encourage the patient/family to smell the area for mustiness or unpleasant odor. If ignored the patient may develop a fever
If the cast or patient is immobilized for a long period of time may suffer from complications of
immobility.
If patient's hand start to swell
elevate
After cast removal
1. Remove dry skin carefully use lotion
2. Expect decreased size and range of motion
3. Support the extremity with pillows until strength returns
4. Exercise slowly and according to rehabilitation instruction
5. Wear support hose for lower extremity injury to prevent edema
i. Compartment Syndrome
-Most common in the tibia and forearm but has other causes
-The edema continues to increase and leads to tissue necrosis and possible tissue infection.
-May appear 6 - 8 hours following an injury or can take up to 2 days to appear
-1. 6 P's
a. Pain
b. Pressure
c. Paralysis
d. Paresthesia
e. Pallor
Pulselessness
i. Compartment Syndrome
Interventions
a. Loosen the bandage or wrap to reduce the symptoms of the syndrome
b. If a cast is present, follow the policy for cast removal
c. Notify the PCP immediately
d. Do Not Elevate or ICE the extremity it may affect the circulation to the extremity.
e. May be treated with fasciotomy - a surgical opening in the fascia of the affected compartment to relieve the pressure and restore circulation. This results in an open wound
f. Wound is packed and dressed daily for 4 - 5 days until the wound is ready to be sutured closed or ready for wound vac therapy. The wound may still be sutures shut or require a skin graft.
1. Traction
a. Prevention of complications
i. Keep extremity properly aligned
ii. Immobility:
1. Skin integrity
iii. Ensure that the traction weight bag is hanging freely, the bag must not rest on the bed or the floor.
iv. If infection occurs:
1. Get culture
2. Contact provider to get antibiotics
1. Visual Impairment
Signs and Symptoms
i. Blurry vision
ii. Squinting
iii. Closing one eye
iv. Leaning close to screens
1. Visual Impairment
Nursing Interventions
i. Knock and announce entrance and exit
ii. Communication to floor staff that they are visually impaired
iii. Orient them to their environment
1. Count steps to bathroom with them
2. don't change the environment
iv. Describe their food placement on the plate in terms of a clock face.
v. Assess if they need assistance to the bathroom
Signs and Symptoms of Visual Impairment
Blurry vision
Squinting
Closing one eye
Leaning close to screens
Nursing Interventions for visual impairment
Knock and announce entrance and exit
Communication to floor staff that they are visually impaired
Orient them to their environment
Count steps to bathroom with them
don't change the environment
Describe their food placement on the plate in terms of a clock face.
Assess if they need assistance to the bathroom
Myopia
Near sightedness, distance vision is poor
Astigmatism
Irregularity or deformity of the shape of the cornea
Oval shape, should be round
Cataracts s/s
Blurred vision
Clouded vision
Decreased color perception
May think that glasses are smudged
Double vision
Halos around objects
Problems with ADL'S
Affects reading and driving
Impaired night vision
Frequents changes in eyeglass prescription
Without surgical intervention blindness follows
Cataract Surgery Post-Op assessment Monitor for
Observe for increasing eye redness
Decrease in vision
Increase in tears
Photophobia
Floaters
Sharp, or sudden pain in eye
Green or yellow drainage on the lids and lashes
NOTE: Creamy, white, crusty drainage on eye lids and lashes is normal, but stress importance of handwashing
Antibiotic and steroid ointment are placed in the eye immediately post-op.
Discharged home one hour after surgery
Wear dark glasses and avoid bright sunlight until pupils respond to light.
Do not drive - Will need ride home
Develop a schedule for the administration of post-op eye drops. Be sure client or family can demonstrate the correct technique for administering the drops.
Be sure the client understands the importance of attending all follow-up appointments.
Itching of the eye is normal.
Eyelid swelling is normal also and can be managed with a cool compress
Discomfort can be managed with Tylenol but aspirin needs to be avoided because it affects blood clotting.
Uncontrolled pain may indicate hemorrhage or increased intraocular pressure and the physician should be notified especially if nausea and vomiting accompanies the pain.
Report Worsening Vision
Discharge planning after cataract Surgery
Develop a schedule for the administration of post-op eye drops. Be sure client or family can demonstrate the correct technique for administering the drops.
Be sure the client understands the importance of attending all follow-up appointments.
Teach them S&S
Restrictions after cataract Surgery
Avoid jarring rapid movements, wear dark sunglasses, no driving themselves home
Hearing Impairment Communication
Face them
Don't yell, speak clearly, slowly
Use whiteboard when necessary
Use interpreter if the patient speaks sign language
Risk Factors for Hearing Loss
Medications
Loud noises over long period (occupational)
Tinnitus
Ringing in the ears
Patient Education for installation of eardrops
place dropper half inch above ear
pull auricle back and out
lay on your side for a couple of minutes to let medication to get into inner ear
How Weber Test is performed
Uses tuning fork
Vibrate tuning fork, first place it on the top of the head and have the patient tell which side they hear the vibrations more on
normal result of Weber test
Vibrations should be equal on both sides
What is cellulitis?
infection of the skin
Interventions of cellulitis
Warm compresses
Elevate the affected area
Reposition patient frequently
scleroderma
hardening of the skin
Wound Assessment Documentation
C: color
O: odor
C: consistency
A: amount
Location
Size
Extent of tissue involvement
Exudate
Slough: refers to the yellow/white material in the wound bed; it is usually wet, but can be dry. It generally has a soft texture. It can be thick and adhered to the wound bed, present as a thin coating, or patchy over the surface of the wound
Eschar
Dead tissue that eventually sloughs off healthy skin after an injury. (a scab)
Serous
clear, watery, typical clean wounds
Sanguineous
Bloody
Serosanguineous
Bloody and serous
Purulent
Pus
Purosanguineous
Bloody pus
clean wound
minimal inflammation
clean-contaminated wound
increased risk for infection (GI surgeries)
Contaminated wound
High-risk for infection (trauma)
infected wound
bacteria count is >100K
superficial wound
damage to epidermis
partial thickness wound
Damage to epidermis and some dermis
Full-Thickness wound
reaches the subcutaneous and could pass.
penetrating wound
involves internal organs
Regenerative or Epithelial Healing wound
when only the epidermis and part of the dermis are lost. No scar forms (shallow blister or skin tear)
First intention wound
wound edges can connect (well-approximated)
second intention wound
wound edges cannot connect need help to heal. E.g. extensive tissue lost, infected
third intention wound
delayed healing than later can be closed (delayed primary healing)
Factors delaying healing
Nutritional status
Age
Disease process
Infection
Smoking
Diabetes
Dehiscence
Dehiscence: sutures popped, nothing poking out
1. Caused by: pressure (coughing, sneezing, laughing)
Evisceration
organs are poking out
caused by
pressure (coughing, sneezing, laughing)
Infection of wound
Purulent drainage
Factors to enhance wound healing
Nutrition: increase protein, amino acids
Hydration
Cleanliness
Improved circulation
Wound Care-Pain Management
Assess pain before dressing changes or a culture
Administer pain meds prior to dressing changes especially wet to dry
Causative factors
Shearing - epidermal layer slides over the dermis and causes damage to vascular beds
Most common when HOB is elevated and patient slides downward
Keep HOB lower than 30˚ to reduce risk
Friction - damages the outer protective layer of the epidermis
Reduces pressure needed to cause skin lesions
Interventions to prevent shearing injury
Never drag patient, use lift devices
Pressure Injuries factors
Mobility status
Impaired sensation
Impaired communication
Mechanical forces: friction and shear. Keep bed at 30° or below
Moisture leads to maceration (soften of the skin)
Impaired nutritional status especially protein malnutrition
Past-history of pressure injuries
Interventions to decrease risk pressure injuries
Pad
Pad hard surfaces with pressure redistribution properties
Do not elevate
Do not elevate head of bed greater than 30 degrees
Suspend
Suspend heels-off the bed surface
Transfer
Use a Hoyer lift for all transfers
Nutrition
Encourage protein intake at each meal
Serve protein shakes between meals
Skin Care
Complete a daily skin inspection
Moisturize dry skin with lotion
Do not massage bony prominences
Skin Cleaning
Clean
Clean skin asap after soiling occurs
Pat
Pat skin dry
Use
Use tepid rather than hot water
stage 1
Skin is intact
Area is red and does not blanche
stage 2
Skin is not intact
Partial-thickness skin loss of the epidermis and the dermis
Bruising is not present
Stage 3
Skin loss is full thickness
Subcutaneous tissue may be damaged or necrotic
Damage extends down to but not through the underlying fascia, bone, tendon, and muscle are NOT exposed
Stage 4
Skin loss is full thickness with exposed or palpable muscle, tendon, or bone
Often includes tunneling and undermining
Slough eschar are often present on at least part of the wound
Unstageable
Skin loss is full thickness; and the base is completely covered with slough or eschar, obscuring the true depth of the wound
Undermining
Wound is extending under the skin [Show Less]