Risk Factors
Name three risk factors for developing pressure ulcers.
What is obesity, poor nutrition, prior skin ulcers, dehydration sensory impairment, smoking
This is how often the Braden Scale should be documented on the nursing flow sheet.
What is every shift?
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear.
What is suspected Deep Tissue Injury
Used on patient's with pressure area's on coccyx or risk for injury when sitting in a chair
What is waffle seat cushion?
When patient's are incontinent of urine this is used as a protective barrier.
What is aloe vista
Greatest risk factor for the pressure ulcer development.
What is Immobility
This will be placed in the progress notes and the front of the chart by the person taking the photo.
What is Yellow Photo taken sticker
Partial thickness skin loss involving epidermis and/or dermis, the ulcer is superficial presenting as a abrasion, blister, or shallow crater
What is Stage 2
When patient's are incontinent of stool this is used as a skin protective barrier
What is calmoseptine
Patient's at nutritional risk should be offered this.
What is high protein supplement
Imobility for what time frame can cause tissue ischemia?
What is 20 minutes
Once pressure ulcer identified, this is taken on initial assessment, every 7 days and on discharge.
What is a photo
Full thickness skin loss with extensive destruction, tissue necrosis, or damage involving muscle.
What is Stage 4
Waffle mattress, waffle seat cushion, waffle boot, first step mattress.
What are pressure relieving devices?
By frequently repositioning patient you can decrease the occurrence of pressure ulcer on which three high risk pressure points?
What is heel, sacrum, hips, knee, occipital, buttocks
Parallel frictional force that occurs as patients are dragged during repositioning as opposed to being lifted and moved.
What is shearing
Patient, Family, Physician, Clinical Supervisor, and Wound Champion Nurse
Who are people the nurse notifies when a patient has a pressure ulcer
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
What is Stage 3
What blood work should be assessed to determine nutritional status?
What pre albumin level
Water filled gloves, sheep skin and do-nut rings
What increases further ischemia if used and should not be used.
This scale is utilized to assess patient's risk factor for pressure ulcers by assessing patient's: sensory perception, moisture, activity, mobility, nutrition, friction, and shear
What is the Braden Scale
Full thickness tissue loss where the base of the ulcer is covered with slough and or eschar in the wound bed.
What is Unstageable
This patient assessed level is done on every admission to identify risk reduction strategies to be utilized for the patient.
What is Prevention Level
What device should be used on patients and checked daily for proper use?
What is air matress