Mobility / LPN-RN Transition Course
Rehab Team
(Ans- collaborative approach, patients are members of the team as well as
family, doctors, OT, PT, and social workers.
PULSES
(AnsAssessment of functional ability
p- physical condition
u- upper limb function
l- lower limb function
s- sensort
e- bladder control
s- supprt
risk factors for developing pressure ulcers
(Ans- immobility, impaired sensory perception, decreased tissue perfusion,
decreased nutritional status, friction and shear, increased moisture
assessment for the prevention of pressure ulcers
(Ans- assessment of skin, evaluate mobility, evaluate circulatory status and
neurological status, evaluate nutrition, broaden scale.
Intervention to prevent pressure ulcer formation
(Ans- relieve pressure, position patient reduction friction and shear,
minimize moisture, improve mobility
stage 1 pressure ulcer
(Ans- Non-blanchable erythema
remove pressure, prevent moisture, promote proper nutrition
Stage 2 pressure ulcer
(AnsPartial thickness
Partial thickness loss of dermis presenting as a shallow open ulcer with a
red pink wound bed, without slough
*clean with sterile saline poly dressing
stage 3 pressure ulcer
(Ans- full thickness skin loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscle are not exposed.
*debide, wet to damp dressing, possible surgical debridement
Stage 4 pressure ulcer
(Ans- Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar may be present.
*surgical debridement maybe needed