Stage It!
Reddened coccyx, skin does not turn white with pressure, skin intact.
What is a stage 1 pressure ulcer?
The primary underlying physiological cause of all pressure injuries resulting from prolonged compression of capillaries.
What is ischemia (or compromised blood flow)?
The minimum turning and repositioning schedule for a bed-bound client
What is every two hours?
Watery, straw-colored, clear drainage commonly seen in clean wounds.
What is serous exudate?
A client with visual impairment is at increased risk for this major safety problem.
What is falls?
A shallow, moist, pink/red open ulcer with partial-thickness loss of the dermis.
What is a stage 2 pressure ulcer?
A wound that can happen due to dragging a patient across sheets, often superficial.
What is a friction injury?
The maximum recommended angle to elevate the head of bed to reduce shearing forces on the sacrum.
What is 30 degrees?
Thick, yellow, tan, or green drainage that contains dead white blood cells, debris, and bacteria indicating infection.
What is purulent exudate?
A client with hearing impairment should have this done before the nurse starts speaking.
What is gain the client’s attention first?
A deep ulcer on the greater trochanter with directly palpable bone, tendon, or muscle.
What is a stage 4 pressure ulcer?
This type of injury occurs due to friction, and force, causing a deep injury to the tissue layers not visible at the surface.
What is a shear injury?
One way you can reduce pressure to feet for a bed bound patient
What is foot cradle, boots/pillows for heel offloading and repositioning?
Beefy red, moist, bumpy tissue filled with new capillary loops found in the base of a healing open wound.
What is granulation tissue?
Name 3 nursing interventions for a client with hearing impairment.
face the client when speaking, gain attention before speaking, reduce background noise, simplify language, ensure hearing aids are in place and working, check batteries if needed
Full-thickness skin loss where yellow subcutaneous adipose tissue is visible.
What is a stage 3 pressure ulcer?
On the Braden Scale, this relationship between score and risk level is a key rule nurses must remember.
What is a lower score indicates a higher risk?
The reason nurses should not massage reddened bony prominences or use donut-shaped cushions.
What is it causes further capillary damage / reduces peripheral blood flow and accelerates tissue breakdown?
The difference between wound dehiscence and wound evisceration.
What is dehiscence is separation of wound edges, while evisceration involves internal organs/viscera protruding through the opening?
These four classic sensations are reported by clients with peripheral neuropathy in their extremities.
What is tingling, pain, burning and numbness?
Coccyx wound base that is completely obscured by thick yellow slough and black eschar.
What is an Unstageable pressure injury?
Name at least 4 of the 6 subscales evaluated on the Braden Scale.
What are Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear?
The daily recommended dietary protein intake range per kilogram of body weight to promote tissue synthesis and wound healing.
What is 1.2 to 1.5 grams of protein/kg/day?
The immediate priority nursing action when sudden wound evisceration occurs.
What is covering the protruding organs with sterile gauze soaked in sterile normal saline and calling for immediate help/notifying the provider?
Name three interventions that can be done to help with visual impairment.
Access to glasses, provide adequate lighting, escribe environment as needed, avoid rearranging the environment, provide large print reading materials, label frequently used items, assist in setting up annual eye exams