Wound Risk Factors
These two areas are the most common for pressure injuries occur
We have a winner! What is sacrum/buttocks and heels?
Applying this during care can help prevent skin tears
What is (Remedy Clinical) moisturizing lotion
This is the largest organ in our body?
What is our skin
Utilize these guidelines on any New admissions, Newly developed skin impairments or when Provider orders have not yet been received
What is the skin and wound guidelines
These must be done on admission and then weekly to ensure prompt identification of any skin concerns
What is comprehensive skin check
This is the number one risk factor for developing a pressure ulcer
What is immobility
This should be applied after care and every Incontinent episodes to prevent moisture associated skin damage and skin break down
What is (Prevent Silicone) Barrier Cream
Be careful not to use these on top of Low air loss mattresses or gel cushions.
We have a winner! What are bedpads or multiple chux
This cream must have an order and is intended for open or denuded moisture associated skin damage
What is Remedy Zinc (Z guard/calazime)
This application is used to accurately measure and document wounds in pcc?
What is swift
This early warning sign shows that a Pressure Injury is developing over an area where pressure is being exerted?
What is Pink or Red skin.We have a winner! See Pink and Think! See something say something!
Always offload these for residents who can not move independently
What is heels
This is the leading cause of injury and accidental death among adults over the age of 65 in the U.S.
What is falls
Always offload these for residents who do not move independently
What is heels
Assessment that is initiated for unwitnessed falls or falls with head injuries ?
What are Neurological assessments
Chronic disease, medication side effects and balance issues are examples of what type of risk factors ?
What is Intrinsic risk factors
Using this to lift or reposition a resident can help prevent friction and shearing injuries
What is slider sheet
These type of medications increase a residents risk of falling?
What are Anticolinergics and Benzodiazepines
Implementing this type of program can reduce unsafe transfer or ambulation due to incontinence, urinary frequency or urgency?
What is a toileting program
This is something we look for after a resident falls to help us prevent future falls?
What is the Root Cause
People over this age are at risk for having injury or death from a fall?
What is 65
A fall that occurs when a patient stands from a sitting or lying position should trigger this type of an assessment by the nurse ?
Orthostatic Blood pressure assessment
Faintness, lightheadedness and dizziness when standing after sitting or lying down are symptoms of this?
What is Orthostatic Hypotension
Appropriate assessment and treatment of this leads to reduction of fall risk and unsafe behaviors related to discomfort ?
What is pain
This is something that must be used if a resident falls to the floor
What is a mechanical lift