Skin Integrity & Pressure Injuries
When completed every 2 hours, this nursing intervention can help decrease the incidence of pressure injuries.
What is turn and reposition?
Jackson Pratt (JP) and hemovac.
What are closed drainage systems?
The right client, right medication, right _____, right time, right route, and right ____ are the 6 rights of drug administration.
What is dose and documentation?
This type of drainage is red.
What is sanguinous?
Full thickness skin and tissue loss.
What is a stage 3 pressure injury?
Placing the medication between the patient's cheek and gum and instructing the client not to swallow.
What is buccal?
What is immobility, moisture, friction, shear, poor nutrition, impaired sensory perception?
Partial thickness skin loss with exposed dermis.
What is a stage 2 pressure injury?
Placing the medication under the client's tongue and instructing them to wait until the medication dissolves.
What is sublingual?
The bottom of the sore is covered with slough and eschar.
What is unstageable pressure injury?
Full thickness skin and tissue loss down to the muscle and, perhaps, bone.
What is a stage 4 pressure injury?
Persistent nonblancheable deep red, maroon, or purple discoloration of the skin.
What is a deep tissue injury?
This scale should be used every shift on high risk patients to determine their risk for skin breakdown.
What is the Braden scale?
A second nurse verification of the medication, route, dose and patient prior to administration of this type of medication. Give an example!
What are high alert medications, such as insulin?