Lesson 41: General NCLEX Pressure Ulcers Notes

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Pressure ulcers are localized injuries to the skin and underlying tissue usually over a bony prominence.

They are mostly caused by four factors:

• prolonged pressure- staying in the same position for too long
• shear-skin moves in one direction while the underlying bone in another (sitting in fowler's position all day)
• friction- force overcomes the body's resistance to movement
• moisture- incontinence, perspiration

The most common sites are:

Oxygen tubing, casts, stockings, boots, traction, etc can all cause pressure ulcers. As a nurse you have to do skin inspections!

What scale is used to assess patients for pressure ulcers? Braden Scale

What patients are the most at risk for pressure ulcers:

• bedridden
• incontinent
• obese
• paraplegic
• fevers (why you ask? Increased metabolism creates oxygen demands that can not be met to compromised areas)

NCLEX Pressure Ulcer Prevention 


Keep skin clean and dry, Reposition patient frequently (q 2hours in bed & q 1 hour in chair), Use pressure ulcer reducing equipment (beds, pillows), Active/Passive Range of Motion, Do not slide the patient in bed, lift to avoid shear/friction