Name three risk factors for developing pressure ulcers.
What is obesity, poor nutrition, prior skin ulcers, dehydration sensory impairment, smoking
100
This is how often the Braden Scale should be documented on the nursing flow sheet.
What is daily
100
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
100
Used on patient's with pressure area's on coccyx or risk for injury when getting out of bed to chair
What is air cushion
100
When patient's are incontinent of urine this is used as a protetive barrier.
What is aloe vista
200
Greatest risk factor for the pressure ulcer development.
What is Immobility
200
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
200
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
200
When patient's are incontinent of stool this is used as a skin protective barrier
What is calmoseptine
200
Patient's at nutritional risk should be offered this.
What is high protein supplement
300
Imobility for what time frame can cause tissue ischemia?
What is 20 minutes
300
Once pressure ulcer identified, this is taken on initial assessment, every 7 days and on discharge.
What is a photo
300
Full thickness skin loss with extensive destructin, tissure necrosis, or damage involving muscle.
What is Stage 4
300
Tempur Med, Decube Matress, and Air Matress
What is pressure relieving devices
300
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
400
Parallel frictional force that occurs as patients are dragged during repositioning as opposed to being lifted and moved.
What is shearing
400
Patient, Family, Physician, Dietary, and Stomal Nurse
Who are people the nurse notifies when a patient has a pressure ulcer
400
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not throught, underlying fascia.
What is Stage 3
400
What blood work should be assessed to determine nutritional status?
What pre albumin level
400
Water filled gloves, sheep skin and donut rings
What is increases further ischemia if used and should not be used.
500
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
500
Full thickness tissue loss where the base of the ulcer is covered with slough and or eschar in the wound bed.
What is Unstageable
500
This patient assessed level is done on every admission to identify risk reduction strategies to be utilized for the patient.
What is Prevention Level
500
What device should be used on patients and checked daily for proper use?