RISK RADAR
This six-subscale tool predicts who is at risk for a pressure injury.
What is the Braden Scale?
Intact skin has a persistent, nonblanchable red area over the sacrum.
What is a stage 1 pressure injury?
Beefy-red, bumpy granulation tissue forms during this wound-healing phase.
What is the proliferative phase?
This dressing protects fragile granulation tissue and minimizes trauma during removal.
What is a nonadherent dressing?
Before preparing a sterile dressing change, this infection-prevention step comes first.
What is hand hygiene?
This soft, open surgical drain allows fluid to escape into a dressing instead of a sealed reservoir.
What is a Penrose drain?
A patient's low Braden score signals this change in pressure-injury risk.
What is increased risk?
A shallow, open injury has partial-thickness skin loss with exposed pink dermis.
What is a stage 2 pressure injury?
A clean surgical incision is closed with the edges brought together; this is healing by ...
What is primary intention?
An appropriate low-exudate wound needs a moisture-retentive, occlusive dressing.
What is a hydrocolloid dressing?
To obtain an accurate wound culture, the nurse first cleanses the wound before doing this.
What is collecting the ordered specimen from viable wound tissue?
After emptying a Jackson-Pratt bulb, the nurse uses this technique to restore suction.
What is compress the bulb and close the cap while compressed?
Name the six Braden subscales.
What are sensory perception, moisture, activity, mobility, nutrition, and friction/shear?
Full-thickness skin loss exposes adipose tissue, but no muscle, tendon, or bone.
What is a stage 3 pressure injury?
An open pressure injury fills with granulation tissue from the base upward; this is healing by ...
What is secondary intention?
An open wound has moderate-to-heavy drainage and needs an absorbent cover.
What is a foam dressing?
During sterile wound care, a gloved hand touches the bedside rail. The nurse should do this next.
What is replace the contaminated sterile glove?
An elastic compression bandage is wrapped from the foot toward the calf in this direction.
What is distal to proximal?
A bedbound patient has reddened heels. Name the positioning action that removes direct heel pressure.
What is floating or offloading the heels?
A heel wound has exposed tendon, muscle, or bone.
What is a stage 4 pressure injury?
A contaminated wound is first left open, then closed after the infection or swelling improves.
What is tertiary intention, or delayed primary closure?
Removing an adhered wet-to-dry dressing removes tissue through this type of debridement.
What is mechanical debridement?
When irrigating a wound, the nurse avoids touching this item to the wound and lets fluid flow into a receptacle.
What is the irrigation syringe or catheter tip?
A postoperative incision partially separates, but no internal organs are visible. Name the complication.
What is wound dehiscence?
A stroke patient is immobile, incontinent, and eating poorly. Identify three priorities for pressure-injury prevention.
What are reposition/offload, manage moisture, and support nutrition?
Contrast a wound covered by slough/eschar with intact skin showing persistent purple-maroon discoloration.
What are unstageable pressure injury and deep tissue pressure injury, respectively?
A malnourished patient has slow wound healing. Name two nutritional priorities.
What are adequate protein and calories, with sufficient hydration?
One method uses the body's own enzymes under a moisture-retentive cover; another uses a topical enzyme.
What are autolytic and enzymatic debridement, respectively?
A sterile dressing change is underway when the nurse notices the new dressing touched an unsterile surface. What is the safest action?
What is discard the contaminated dressing and obtain a new sterile one?
A patient coughs and bowel protrudes through an abdominal incision. State the immediate protective action and escalation.
What is cover with sterile normal-saline-moistened gauze, flex knees, and summon urgent help/notify the provider?