Risk Factors
What type of assessment tool should be used to identify a person's risk of developing a pressure injury?
Braden Scale
How often should skin assessment and inspection occur as part of the prevention plan
Daily
What is one important daily action for preventing pressure injuries
Inspect the skin and provide daily skin care
What does the acronym SMART stand for when setting goals of care
Specific, Measurable, Attainable, Relevant and Timely
What should the team do if the goals of care have not been fully met
Reassess the person, wound, environment and system, then revisit the care plan
Name one factor that increases the risk of developing a pressure injury
reduced mobility, moisture exposure, impaired sensation, inadequate nutrition or hydration, friction or shearing, and vascular disease.
Pressure injuries commonly occur over what type of body area
A bony prominence or a site exposed to external pressure and shear
What type of support surface helps reduce pressure on vulnerable areas
A pressure redistribution support surface
Who should be included as a member of the pressure injury prevention and management team?
The person receiving care, along with their family or care partners and relevant health-care professionals
What is one outcome that can be used to evaluate a pressure injury prevention plan
Prevention of a pressure injury, consistent daily skin care, effective pressure/shear/moisture management, or prevention of infection.
What two mechanical forces, in addition to pressure, should staff work to minimize
Friction and shear
A bony prominence or a site exposed to external pressure and shear
Localized heat, edema, or a change in tissue consistency, such as hardness or induration.
What should staff do to reduce pressure and shear during transfers and repositioning
Use safe repositioning and transfer techniques, appropriate positioning, transfer aids and pressure redistribution surfaces.
What is the main purpose of an individualized pressure injury care plan
To address the person's needs and risk factors, correct causes or contributing factors, and support skin health or wound healing
What is osteomyelitis
An infection involving bone
Why can inadequate nutrition and hydration affect pressure injury prevention and healing?
risk factors that can affect skin integrity and wound healing.
What is one key difference between a Stage 2 pressure injury and incontinence-associated dermatitis (IAD)?
A Stage 2 pressure injury is typically a shallow open area with distinct edges over a pressure- or shear-exposed area. IAD is generally more diffuse with poorly defined edges and is associated with urinary or fecal incontinence.
How can staff help manage moisture associated with incontinence
Use individualized bowel and bladder programs, appropriate absorbent products, skin barriers and moisture-wicking materials as indicated.
What type of cleanser does the resource recommend for wound cleansing
A non-irritating cleanser, such as water, normal saline or a commercially prepared wound cleanser, depending on the person's needs
A resident develops a pressure injury despite an established prevention plan. What should the team do next?
Reassess the resident and contributing factors, review whether interventions are being implemented consistently, and adjust the plan as needed
A resident has reduced mobility, impaired sensation and frequent moisture exposure. What should staff do with this information?
Recognize the increased risk, assess the resident's skin and risk factors, and use the findings to guide prevention and care.
When categorizing a pressure injury, should staff use its original depth of injury or its current depth as it heals?
Use the depth of the original injury. Do not reverse-stage it as healing occurs.
A resident is spending prolonged periods in bed and has increasing redness over a bony prominence. What prevention measures should be reviewed?
Positioning and repositioning, pressure redistribution, safe transfers and mobility, skin care, moisture management, and the resident's overall risk factors
Besides choosing a dressing, name two other elements of local wound environment management.
Cleansing, debriding non-viable tissue when appropriate, managing bacterial balance and infection, or managing moisture balance.
What is the key principle behind the statement, “It’s not what you put on a pressure injury, it’s what you take off a pressure injury”?
Reducing or removing the pressure and other contributing forces is essential; wound dressings alone do not address the underlying cause