Pressure Injuries: I-stage, I-turn, Pakainin

🧠 Bakit mahalaga

STAGE 1: buo ang balat na may NON-BLANCHABLE na pamumula; sa mas maitim na balat, hanapin ang pagbabago ng kulay, init, tigas o sakit. STAGE 2: partial-thickness na pagkawala na may mababaw na bukas na sugat o buo o pumutok na paltos, kulay rosas at basa, walang slough. STAGE 3: full-thickness na pagkawala na may nakikitang taba, posibleng may undermining; walang nakikitang buto o tendon. STAGE 4: full-thickness na pagkawala na may nakalantad na buto, tendon o kalamnan. UNSTAGEABLE: natatakpan ng slough o eschar ang base kaya hindi makita ang lalim. DEEP TISSUE injury: buo o hindi buong balat na may tuloy-tuloy na kulay ube o maroon. I-assess ang risk gamit ang BRADEN scale (sensory perception, moisture, activity, mobility, nutrition, friction at shear); ang mas mababang score ay mas mataas na risk, at ang 18 pababa ay itinuturing na at risk. Pigilan sa pamamagitan ng repositioning kahit tuwing 2 oras man lang, pressure-redistribution surfaces, 30-degree na lateral tilt, nakalutang ang mga sakong sa kama, head of the bed na hindi mas mataas kaysa kailangan para limitahan ang shear, moisture management, at sapat na protein at calories. Huwag i-massage ang mga namumulang bahagi at huwag gumamit ng donut-shaped na cushion.

STAGE 1: intact skin with NON-BLANCHABLE redness; in darker skin, look for color change, warmth, firmness or pain. STAGE 2: partial-thickness loss with a shallow open wound or an intact or ruptured blister, pink and moist, no slough. STAGE 3: full-thickness loss with visible fat, possibly undermining; no bone or tendon visible. STAGE 4: full-thickness loss with exposed bone, tendon or muscle. UNSTAGEABLE: the base is covered by slough or eschar so depth cannot be seen. DEEP TISSUE injury: intact or non-intact skin with persistent purple or maroon discoloration. Assess risk with the BRADEN scale (sensory perception, moisture, activity, mobility, nutrition, friction and shear); lower scores mean higher risk, with 18 or below considered at risk. Prevent with repositioning at least every 2 hours, pressure-redistribution surfaces, a 30-degree lateral tilt, heels floated off the bed, the head of the bed no higher than needed to limit shear, moisture management, and adequate protein and calories. Do not massage reddened areas and do not use donut-shaped cushions.

🏥 Sa totoong buhay

🦶 Ang pasyenteng hindi makagalaw ay may 2 cm na bahagi ng kulay ube, buo at malambot na balat sa sakong. Ni-chart ng bagong nurse na 'stage 1'. Itinama ito ng may karanasang nurse bilang deep tissue pressure injury, inilutang ang mga sakong sa unan, at nag-ayos ng dietitian consult para sa mababang albumin ng pasyente. Hindi pula ang ube, at ang staging ang nagpapasya sa wound plan.

🦶 An immobile client has a 2 cm area of purple, intact, boggy skin on the heel. A new nurse charts 'stage 1'. The experienced nurse corrects it to deep tissue pressure injury, floats the heels on a pillow, and arranges a dietitian consult for the client's low albumin. Purple is not red, and staging decides the wound plan.

📌 Tandaan

• Ang non-blanchable na pamumula ay stage 1 naNon-blanchable redness is already stage 1
• Ang unstageable ay natatakpan ng slough o eschar; ang deep tissue injury ay kulay ube o maroonUnstageable means covered by slough or eschar; deep tissue injury is purple or maroon
• Braden 18 pababa: at risk; i-turn q2h, ilutang ang mga sakong, protektahan sa moisture at shearBraden 18 or below: at risk; turn q2h, float heels, protect from moisture and shear

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