Pressure Ulcers

Key Values & Ranges

Localized injuries from sustained pressure over bony prominences. Staged 1-4, unstageable, and DTPI. Prevention, staging, and reporting extensively tested on CNA and MA exams.

Resident care connections: Right to access personal records and facility survey results. Right to manage own financial affairs or choose a representative.

Assessment Techniques

Assessment observations for pressure ulcers that must be reported to the nurse:

• Behavioral changes: new confusion, agitation, refusing meals, sleep pattern changes
• Report to nurse: elevated temperature, blood pressure outside baseline, new pain, skin breakdown
• Fall risk factors: history of falls, medications (sedatives, diuretics), mobility impairment, cognitive decline
• I and O (intake and output): measure and record all fluids consumed and excreted in mL
• Weight changes: report gain/loss of 2+ lbs in a day or 5+ lbs in a week

Common Errors

Common nursing assistant errors with pressure ulcers:

• Not applying proper body mechanics: wide base of support with feet shoulder-width apart, one foot slightly forward; push rather than pull when moving objects or residents; keep load close to body to reduce spinal strain
• Forgetting to identify the resident before providing care
• Not reporting changes in condition promptly to the nurse
• Performing tasks outside the CNA scope of practice

Professional Standards

Professional standards for pressure ulcers are established by the relevant certification body and regulatory agencies. Certified professionals must demonstrate competency through examination and maintain credentials through continuing education. Scope of practice is defined by state law and facility policy. Never perform tasks outside your authorized scope.