Risk Factors
What is the greatest risk factors for a pressure ulcer after a CVA?
What is immobility?
This tool predicts a patient's risk for pressure injuries.
What is the Braden Scale?
What nutrient should Mr. Jones increase to promote wound healing?
What is protein?
How often should Mr. Jones be repositioned in bed?
What is every 2 hours?
This stage has intact skin with non-blanchable redness.
What is Stage 1?
This condition causes excess moisture that increases skin breakdown.
What is urinary incontinence?
A Braden score of 12 places Mr. Jones in what risk category?
What is High Risk?
What should be applied after episodes of urinary incontinence to protect the skin?
What is barrier cream?
What type of mattress helps reduce pressure on bony prominences?
What is a low-air-loss?
Mr. Jones's coccyx wound has partial-thickness skin loss with exposed dermis. What stage is it?
What is a Stage 2 pressure injury?
This age group has thinner, more fragile skin and is at greater risk.
Who are older adults?
A lower Braden Scale score indicates what?
What is a higher risk for pressure ulcers?
What should the nurse monitor to evaluate Mr. Jones's nutritional status?
Patients at high risk should be repositioned at least every __ hours in bed.
What is every 2 hours?
Why should treatment begin as soon as pressure injuries are identified?
To prevent worsening, infection, and delayed healing.
Name three risk factors from Mr. Jones case that increase his risk for pressure injuries
Any three: left-sided weakness, immobility, urinary incontinence, poor nutrition, dehydration, advanced age.
Name three Braden Scale categories.
Sensory perception, moisture, activity, mobility, nutrition, friction & shear?
Besides protein, what should be encouraged if not contraindicated to support healing?
What are fluids (hydration)?
How often nurses should assess Mr. Jones skin?
What is at least once every shift (or daily)?
Who should be consulted after Mr. Jones's pressure injuries are identified?
What is the wound care nurse?
Explain how Mr. Jones's CVA contributes to his risk of pressure injuries.
The CVA caused left-sided weakness and decreased mobility, making it difficult for him to reposition himself and relieve pressure.
Explain why the Braden Scale is an important nursing assessment for Mr. Jones and how it guides his plan of care.
It identifies his risk level, allowing nurses to implement interventions such as frequent repositioning, skin assessments, nutritional support, and moisture management.
Name three nursing interventions to manage Mr. Jones's urinary incontinence.
Check frequently for wet briefs, change promptly, keep skin clean and dry, apply barrier cream, reposition often.
Name four interventions that help prevent pressure ulcers in Mr. Jones
Reposition every 2 hours, float heels, use pillows, pressure-relieving mattress, daily skin assessments.
Mr. Jones has two pressure injuries. Which wound should receive the highest priority for treatment, and why?
What is the coccyx wound because it is a Stage 2 pressure injury with partial-thickness skin loss?