Know Your Risk
This standardized tool helps nurses identify patients at risk for pressure injury.
What is the Braden Scale?
Full-thickness skin loss with visible adipose tissue, but no exposed fascia, muscle, tendon, cartilage, or bone.
What is a Stage 3 pressure injury?
Name one common device that can cause a pressure injury around the nose, cheeks, or ears.
What are BiPAP/CPAP masks, oxygen tubing, NG tubes, etc.?
This simple intervention reduces prolonged pressure over the sacrum and other pressure points.
What is repositioning/offloading?
You remove your patient's socks and discover red heels. What is your first assessment question?
Does the redness blanch?
Then assess skin integrity, temperature, tenderness, surrounding tissue, and offload.
Name three major pressure-injury risk factors commonly seen in acutely ill patients.
What are immobility, poor perfusion/hemodynamic instability, moisture/incontinence, malnutrition, altered sensation, advanced age, medical devices, vasopressors, etc.?
The wound bed is obscured by slough or eschar, preventing you from determining the full depth of tissue damage.
What is an unstageable pressure injury?
These lower-extremity devices should be removed regularly so the nurse can assess the skin underneath.
What are SCDs/compression devices?
Floating these completely off the bed surface helps prevent a common ICU pressure injury.
What are the heels?
Your patient has a sacral foam dressing in place. Can you document that the sacrum is intact without looking underneath it?
No. The skin must actually be visualized and assessed.
Your patient's Braden score improved today. Does that mean pressure-injury precautions can automatically be discontinued?
No. The score supports assessment, but nursing judgment and the patient's overall clinical risk still matter.
Intact skin with nonblanchable redness over a bony prominence.
What is a Stage 1 pressure injury?
An intubated patient needs more than an oral assessment. Name two areas you should inspect for pressure from the airway equipment.
Lips, mouth corners, cheeks, ears, neck, skin beneath the securing device, etc.
True or false: A specialty mattress eliminates the need to reposition a patient.
False.
Wound Care Wednesday.
An intubated patient with septic shock, diarrhea, poor nutrition, and limited mobility has several risks. Name four.
Immobility, moisture, poor perfusion, malnutrition, devices, critical illness, vasopressor use.
Partial-thickness skin loss with exposed dermis; the wound bed is pink/red and there is no visible adipose tissue.
What is a Stage 2 pressure injury?
True or false: If a medical device is functioning correctly, the skin underneath it does not need to be assessed.
False.
Moisture from urine, stool, perspiration, or wound drainage increases the risk for skin damage. What nursing intervention helps protect the skin?
Moisture management, prompt cleansing, barrier products, appropriate containment, frequent reassessment, etc.
During bedside report, you notice an area of new nonblanchable redness that was not previously documented. What should happen next?
Assess it thoroughly, initiate/offload prevention measures, document findings, notify/escalate appropriately, and follow the facility process for newly identified skin injury.
A patient receiving multiple vasopressors is at greater skin risk primarily because of this physiologic problem.
What is decreased peripheral/tissue perfusion?
Persistent deep red, maroon, or purple discoloration that may be intact or non-intact skin.
What is a deep tissue pressure injury (DTPI)?
A pressure injury caused by a medical device generally takes the shape or pattern of what?
The device.
Name four components of a strong pressure-injury prevention bundle, like the HAPI Standard.
Any four: skin assessment, repositioning, offloading, moisture management, nutrition support, support surface, device assessment, mobility, patient/family education.
A septic shock patient on norepinephrine and vasopressin has intact skin but is immobile, edematous, incontinent, and poorly nourished. The question: Do you wait for redness before intensifying prevention?
Absolutely not. This is a high-risk patient who warrants aggressive prevention before visible injury occurs.