Pressure Injury Documentation
This is the magic hour of a pressure injury documentation to determine if the wound is present on admission or a hospital acquired pressure injury.
What is 12 hours?
This is an example of when a gait belt should be utilized.
What is ambulating with a patient for the first time or if the patient is assessed as unsteady on their feet during transitions?
The number and type of layers/products to use with an air loss surface.
What are 2 layers consisting of 1 flat sheet and 1 chux pad?
This pressure injury has exposed bone in a sacral wound
What is a stage IV pressure injury?
This is a trick to amplify a potential wound on a patient with darker pigmentation on their heel.
What is applying lotion or utilizing a bath wipe to the heel?
This is the time frame you have to document your initial skin assessment for a new admission.
What is 12 hours from the entry of the admission order.
These are 4 potential patient benefits to getting a patient out of bed.
What is decrease the likelihood of a pressure injury, maintain the patient's strength, decrease the likelihood of NVHAP, and decrease the likelihood of needing a SNF?
It comes in a purple tube and often is referred to as the "pretty" cream.
What is Remedy nourishing cream?
This pressure injury can present as a fluid filled blister on a heel.
What is a stage II pressure injury?
It's a holiday, the Wound and Ostomy Care Department is closed. These are you next steps to obtain your patient a specialty bed.
What is reaching out to your nursing supervisor?
This Braden score is when you should be entering a consult for Wound Care.
What is a Braden score of 15 or less?
What is the Sara Steady?
The product that is to be used on the patient when they have an invasive line.
What are CHG wipes?
This pressure injury is dry, black and necrotic, but also moist and tan.
What is an unstageable pressure injury?
Your patient has a wound on their bottom, what are the next steps?
What is obtain a photo after cleaning, consult Wound Care and place a dry or wet to dry dressing?
This Braden score is when you should be documenting positioning aids in your charting.
What is a Braden score of 18 or less?
True or False: a physical therapy assessment is required prior to nursing mobilizing and getting the patient up and out of bed.
What is false?
This piece of equipment is not to be used on the ear, but is frequently found there. What is the product and the recommended location for this product?
What is the Nasal Alar SpO2 sensor which is recommended for use on the nare?
This wound is intact, non-blanchable deep red over a pressure point or under a medical device.
What is a Deep Tissue Injury?
Mr. Jones is admitted with a home wound vac. These are the next steps to manage the wound.
What is remove the home wound vac, consult the Wound and Ostomy Care Department, place a dry or wet to dry dressing.
This is the frequency for documenting pressure injuries which have an intact dressing in place.
What is with every shift or any change in condition?
True or False: Patients on ventilators cannot get up to sit in a chair and cannot walk in the hallway with the ventilator.
What is false?
This pressure injury prevention product should never be placed/used in the bed.
What is a waffle cushion?
When described, this pressure injury is often compared to an apple that has been bitten deep but NOT to the core.
What is a stage III pressure injury?
This is the frequency you should monitor the IV of your infant patient.
What is every hour?