STAGES & WOUNDS
non blanching area of skin that is otherwise intact
STAGE 1
How often do you turn a patient?
Q2H
What are some relatively new therapies for pressure ulcer prevention?
-Prophylactic dressings
- Microclimate control
-Fabrics and textiles
--Electrical Stimulation
When conducting a nutrition screening what are some of the factors that nurses should consider?
-Hydration
-Energy intake
-Protein Intake
-Vitamins and minerals
SKIN CONDITIONS ASSOCIATED WITH MOISTURE
MOISTURE ASSOCIATED SKIN DAMAGE
represents a partial loss of the dermis, with no visible adipose fat
STAGE 2
How can you prevent pressure ulcer development on patient's heels?
Off load heels
What are support surfaces that control moisture and temperature?
Microclimate control
According to the National Academy of Sciences, Engineering and medicine how much liquid intake should a man have per day?
-3.7 L
When a large amount of force is exerted on one area for a prolonged period of time
PRESSURE
full tissue and skin loss that occurs with visible tissue and/ or bone
STAGE 4
According to NUPAP pressure ulcer prevention guidelines, what is the maximum amount of time that a nurse should take to assess the patients skin after admission?
8 hours
What is a polyurethane dressing that is applied to bony prominences called?
-Prophylactic dressing
According to the National Academy of Sciences, Engineering and medicine how much liquid intake should a woman have per day?
2.7 L
What do the following FACTORS describe?
skin maceration
AMS
altered nutrition
decreased mobility
Risk factors
wounds with black slough known as eschar. The wound cannot be adequately assessed because of the presence of eschar that obscures the wound bed
UNSTAGEABLE
According to NUPAP when should you reassess patient risk?
-change in acuity/status of the patient
Textiles and Clothing: What fabric should patients wear in order to minimize friction and shear.
- cotton or cotton blended fabrics
For patients at risk for pressure ulcer development how much protein should that have per day?
1.23-1.5 grams of protein per day.
What do you call the name of the pressure ulcer prevention protocol that this campaign is based on?
"On Time" by the Agency for Healthcare Research & Quality
full thickness skin loss that extends into underlying subcutaneous fat
STAGE 3
When assessing darkly pigmented skin what are some of the things you want to consider?
- skin temperature
-edema
-condition of the tissue in relation to surrounding tissue
A pressure ulcer prevention therapy that has no specific recommendations about use. It involves the use of stimulation of muscles to prevent pressure ulcers. It is especially implicated for patients with spinal cord injury.
Electrical stimulation
When a patient has a stage 3 or 4 pressure ulcer what nutritional supplements would the nurse expect to give?
- High protein
-Arginine
- Micronutrients
2 male names that are used as screening tools for pressure ulcer prevention
Braden and Norton