Injured Patients
This patient population frequently experiences decreased mobility and sensation, placing them at an increased risk for pressure injury development.
SCI patients
What is the earliest visible sign of a stage 1 pressure injury?
Non-blanchable redness
This medical device, used for immobilization, is responsible for many hospital-acquired device-related pressure injuries.
Cervical collar
What is the risk assessment tool that should be completed on admission and reassessed throughout hospitalization
Braden Scale
For an immobile patient who spends most of the day in bed but sits in a chair for two hours twice daily, when is the highest immediate risk for developing a pressure injury if no prevention measures are applied?
Both when chairfast and bedfast
(Short periods of high pressure and longer periods of low pressure have the same effect)
A patient with multiple rib fractures is avoiding movement because of pain. What pressure injury risk factor does this create, even if the patient is physically able to reposition themselves?
Immobility (or decreased mobility)
A patient has darkly pigmented skin. This pressure injury assessment finding may be more difficult to identify.
Erythema (Redness)
Name 3 areas that should be assessed when caring for a patient with a cervical collar
A patient scores a 12 on the Braden Scale. What category of risk does this represent?
High Risk
Offload pressure and assess skin. Provide hygiene, change out pads
A patient with bilateral lower extremity fractures is on strict bedrest. What two body areas should receive special attention during skin assessments?
Are all pressure injuries preventable?
No, but if consistent prevention measures are appropriately applied, the risk is reduced to less than 20%
A patient has oxygen tubing in place continuously. Name 2 commonly overlooked pressure points.
Ears and cheeks
A patient has blanchable redness to the coccyx. Why is documentation important even though it is not yet a pressure injury?
To establish a baseline and monitor for progression
A patient experiences frequent diarrhea during their shift. Which pressure injury risk factor is increased because of this?
Moisture (or moisture exposure)
This common trauma diagnosis may cause cognitive deficits that limit a patient's ability to recognize discomfort and request repositioning.
This tissue is often damaged before visible skin changes appear.
Muscle tissue
A patient returns from surgery with a bulky splint. What should the nurse assess beneath or around the device?
Skin integrity and pressure areas
What should be done if a patient or family member refuses pressure injury prevention measures, even after providing education on its importance?
Document refusal along with education provided, escalate concern (provider, charge nurse, etc.), and follow facility procedures (Refusal form completion)
Name four common contributing factors identified during HAPI reviews
Missed assessments, inadequate repositioning, moisture exposure, device related pressure, poor nutrition, delayed recognition, surfaces
A patient with a pelvic fracture has been in bed for four days and refuses turns due to pain. Name four interventions that could help reduce pressure injury risk.
Pain management before repositioning
heel offloading
foam dressing
PT/OT involvement
Continued patient education
A patient has intact purple discoloration over the coccyx after prolonged immobility. What type of pressure injury is suspected?
Deep tissue injury
Name 5 medical devices commonly found on TPCU patients that can contribute to pressure injuries.
NG tubes, peg tubes, foley tubing, BiPAP/CPAP, C-collar
Name 3 documentation findings that would support pressure injury prevention efforts during a chart review.
Skin care plan, repositioning, Braden assessment, mobility documentation, hygiene, offloading interventions, moisture managment
A patient has a cervical collar, multiple fractures, bedrest orders, Braden score of 11, is incontinent, and has a poor appetite.
What interventions should be considered to prevent pressure injury?
Q2 turning, heel offloading, Qshift skin assessments, Skin care plan, hygiene, c-collar care, moisture management, protein supplementation/dietician consult, specialty mattress, foam dressings, Mobility progression, PT/OT, education, accurate documentation