Stage I:Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk) (FROM THE NPUAP – 2007)
Intervention for Stage 1 pressure ulcers
Position patient off affected reddened area
Initiate turning schedule
Consider turning every two hours (3o degree turns off bone)
If the head of the bed has to be greater than 30 degrees turn every one hour
Keep skin clean, dry and supple.
Place protective barrier cream or hydrocolloid over the ulcer
Suspend heels or place in boots that will suspend the heels
Initiate a Dietary Consult (Nutrition assessment)
Remove the cause or the source of the ulcer including:
Divert urine moisture with catheterization
Divert liquid stool with Flexi-Seal Fecal Management System (ConvaTec)
Perform risk assessment and then place the patient on the appropriate pressure distribution mattress
Teach and document patient and family how to and the importance of shifting weight
Matthew Livingston R.N. C.W.S.
