Stage that wound!
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer
What is stage 4?
What is it when the skin turns white when pressed and then returns to color, indicating perfusion?
blanching
The minimum amount of time to reposition your patient
every 2 hours (including in chair!)
This area should be covered by Mepilex Border (especially for immobile patients)
Sacrum
Who should you be calling first to help you with strings
RT (our airway experts!)
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister
What is deep tissue injury?
How often should you be assessing the skin underneath a patients tracheostomy ties?
At least once a shift
What dressing can be applied to skin folds to absorb moisture like sweat?
Interdry
What are patients in the PCU prone to getting pressure injuries by?
Medical Devices
Who can you call for a second opinion for looking at skin?
Non-blanchable redness
What is stage 1?
How often should a head-to-toe skin assessment be documented in EPIC?
Every shift
What is included in the comfort glide turning system?
Turn sheet, ultrasorb underpads, and wedges
This is an area that infant patients are especially at risk for getting a pressure injury on
Occiput
Who can confirm a pressure injury?
Skin Champion and CNS
A shallow open ulcer with a red or pink wound bed
What is stage 2?
Where should you document progress on existing wounds?
LDA
These should be rotated every 4 hours to prevent pressure injuries
Pulse ox probe
Name one of the sub scores on the BradenQD
Mobility, Sensory Perception, Friction and shear, Nutrition, Tissue Perfusion & Oxygenation, Number of Medical Devices, Repositionability/Skin Protection
What is the process when suspecting a skin injury?
Take picture (and label area and location!) in media tab
Alert any skin champions on that shift
Inform CNS and FLOC
Create LDA
File KAPS
Pass on to next nurse
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar
What is unstageable pressure injury?
Which areas are especially important to check during a skin assessment for bedridden patients?
Heels, sacrum, elbows, scapula, and occiput
30 degrees
What tool do we use to rank pressure injury risk on patients?
Braden QD
Who should be consulted for reportable injuries (stage 3 or higher)?
Wound Care!