Pressure Ulcer Stages
A pressure ulcer that involves muscle, tendon, or bone.
What is a Stage 4?
MD order for SN to remove staples with no further assessments needed.
What is not skilled.
Need to have a skilled need with intermittent nursing care.
A patient who remains in bed at all times by choice would automatically be considered "Bedbound".
True or False
What is false.
Scored on ability.
A traumatic wound that is sutured.
What is Not a surgical wound.
A shallow ulcer with no slough, doesn't granulate, and heals by epithelialization.
What is a stage 2 pressure ulcer?
Skilled nurse to do monthly medication set up.
What is not skilled
Intermittent nursing care, but not skilled need.
The ability to get food from the cooking/prep area to the table is captured in M1870?
True or False
What is False.
Question is asking on function of eating.
A port that was place a year ago.
All implanted ports are considered surgical wound.
A pressure ulcer that has slough and/or eschar and can tunnel and undermine.
What is a stage 3 pressure ulcer?
CHF exacerbation with medication management.
What is skilled need.
Skilled need to assess & educate with intermittent nursing visits.
M1860 cannot indicate a patient can shower if they are unable to access a shower?
True or False
What is True.
Surgery performed on the eye.
What is not a surgical wound.
Surgical incisions on mucous membranes or eyes are not considered surgical wounds.
A pressure ulcer that doesn't blanche and is intact.
What is a stage 1 pressure ulcer?
Skilled nurse to do monthly suprapubic cath changes.
What is skilled need.
Changing cath is skilled and needs done monthly so intermittent as well.
A chair may be used to test a patient's ability to safely use a bedside commode if the commode hasn't yet been delivered to the home.
True or False
What is false.
Can not mark ability if device is not in the home.
A fistula that was placed 2 months ago with no complications.
What is not a surgical wound.
A fistula is considered a surgical wound for the first 30 days, then considered non surgical if no complications to healing.
A pressure ulcer that has discolored intact skin, and may evolve into a thin blister over a dark wound bed?
What is unstageable Deep tissue injury?
Skilled nurse to provide daily wound care.
What is skilled.
When a patient has showered despite physician orders not to do so the clinician must select a response reflecting the ability to use the shower.
True or False
False.
MD orders trump patient's ability.
A pain pump that was placed 2 years ago with no skilled nursing treatment needed.
What is a surgical wound.
Implanted infusion devices are always considered surgical wound whether nurse is providing care or not.