One of the client feels strange and all of a sudden she's all sweaty. I checked her blood pressure and it was low. She's conscious so i asked her to drink some water and move her to her bed and elevate her lower legs. Checked her Vital signs again and it went up a little so i keep doing what i'm doing then report the incident to my nurse on duty.
1 - skin intact, non blanchable, localized redness 2 - intact, open blister, reddish pink 3 - full thickness skin loss, possible visible fat, no bone/muscle 4 - full thickness skin loss w/ bone, muscle, or tendon visible unstageable - full thickness w/ slough (scabbing) and necrotic tissue present