Risk Factors
Documentation
What's my Stage
Prevention
Prevention 2
100
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

Use for sitting or while in bed. Good for ICU patients on Vasopressor

What is a waffle cushion


100

Use for “at risk” skin barrier protection, tx for partial thickness skin injury, and as barrier for peri-stomal tube drainage

What is Zinc Oxide Paste Skin Protectant

200
Greatest risk factor for the pressure ulcer development.
What is Immobility
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

Unit based Clinical Research Nurses who have a strong interest in wound, ostomy, and continence nursing and serve as resources and liaisons to their fellow staff.

Who is the Skin Wound Action Team (SWAT)

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

Full thickness skin loss with extensive destructin, tissue necrosis, or damage involving muscle.

What is Stage 4

300

Make sure to apply within the Sacrum gluteal fold. Do Not tent over Or Type “Mepilex” fold, must maintain contact with skin or will create moisture.

What is a  Sacral Mepilex border

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, Wound Care Nurse and  Dietary

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

Assess Skin, Reduce Pressure, Manage Nutrition, Manage Moisture, Maximize Mobility and Reduce Friction and Shear

What is Pressure Injury Prevention Bundle of Care

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

Wicks moisture from skin on skin folds. Antimicrobial. Leave 4” tail out so moisture will wick away from skin

What is Interdry AG wicking textile

500

Flatten before turning. Turn Or Type “Positioner” patient and place under patient then squish it toward the body to keep pt in place

what is  a Z-flo positioner

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