Pressure Injury Prevention
The assessment is used to assess sensory perception, moisture, activity, mobility, nutrition, and friction/sheer.
What is the Braden scale
Would has skin intact with localized non-blanchable erythema.
What is a stage 1 pressure injury
You press down on skin and it does not turn white or pale, and instead stays red
What is non-blanchable (a sign of stage 1 pressure injury)
Can be applied to stage 1 pressure injuries where skin is intact
What is barrier cream or a Mepilex dressing (if risk of shear)
The occiput, shoulders, elbows, sacrum, coccyx, hips, knees, ankles, and heels are all at an increased risk of pressure injuries because they are...
What is bony prominences
The wound is full thickness loss of skin in which the adipose tissue is visible, and you can see granulation tissue, rolled edges, and slough
What is a stage 3 pressure injury
What is black, brown, or tan necrotic tissues on the wound bed or edges
What is eschar
This type of dressing is often used in stage 2 pressure injuries for light exudate, promotes autolytic debridement, and is contraindicated for infected wounds
What is hydrocolloid dressing
It is recommended to reposition patient ______ to relieve prolonged pressure on the skin
What is Q2h
This wound is partial thickness with exposure of dermis. The wound bed is pink.
What is a stage 2 pressure injury
What is the new tissue called that grows back as pressure injuries heal, often is beefy red or bright pink
What is granulation tissue
This dressing is highly absorbent for heavy exudate, is made of seaweed, and should never be placed on dry wound and dry intact peri wound skin.
What is alginate dressings
What are patient-related conditions that affect a person’s ability to tolerate pressure or impact skin healing
What is decreased perfusion, chronic illness, advanced age, low body weight, obesity, altered mental status, medications, history of pressure injuries, malnutrition, pain, or incontinence
This wound is full thickness skin loss with exposure of the muscle. There is 40% slough, 10% eschar, 50% granulation tissue.
What is a stage 4 pressure injury
What kind of wound has full thickness skin loss, the extent of the depth of the tissue damage cannot be confirmed as the view is obscured by eschar or slough
What is an unstageable pressure injury
What kind of dressings is a Mepilex dressing
what is a polyurethane foam dressing (soft silicone foam)
When a patient is lying supine where can be pillows be placed to relieve pressure on bony prominences
What is under occiput, shoulders, hips, and ankles/heels
There is erythema to a bony prominence where pressure was applied for a long period of time and upon pressure to the site it blanches.
What is not a pressure injury yet, but can develop into one if no interventions are put in place.
During a wound assessment, the proportion of eschar, slough, and granulation tissue are measured using which mathematical unit
What is a percentage (has to equal 100%)
What solution is appropriate for cleansing most wounds
What is normal saline