Risk Factors
Name three risk factors for developing pressure ulcers.
What is obesity, poor nutrition, prior skin ulcers, dehydration sensory impairment, smoking?
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 shearing.
What is the Braden Scale?
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shearing.
What is a suspected Deep Tissue Injury?
This should be performed every two hours for "at risk" residents.
What is turn and reposition?
A set of predetermined orders for wound care.
What are nurse-driven order sets?
Greatest risk factor for the pressure ulcer development.
What is Immobility?
Pressure injuries commonly form over.
What are bony prominences?
Partial thickness skin loss involving epidermis and/or dermis; the ulcer is superficial presenting as a abrasion, blister, or shallow crater.
What is a Stage 2?
Name two devices that are used to offload pressure.
What are air mattress, heel lifts, wedges, and pillows?
This is ordered for patients with a nutritional risk.
What is a dietary consult?
What is 20 minutes?
The Larsen Health Center places wound care consults for these types of pressure injuries.
What are Stage III, IV, and Unstageable?
Full thickness skin loss with extensive destruction, tissue necrosis, or damage involving muscle.
What is a Stage 4?
This food group is extremely beneficial when a wound present.
What is protein?
Name three high risk pressure points on the body.
What are the heel, sacrum, coccyx, hips, knee, occipital, and buttocks?
Occurs when internal body structures and skin tissues move in opposite directions.
What is shearing?
The number of Braden Scale categories.
What are 6?
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?
Whiteness that appears when pressure is applied to a reddened area.
This is the main difference between a Stage I and Stage II pressure injury.
What is a break in skin?
A Braden scale score of this means the resident is "at risk."
What is 18 or less?
The force that occurs when two surfaces rub together.
What is friction?
Full thickness tissue loss where the base of the ulcer is covered with slough and or eschar in the wound bed.
What is Unstageable?
Two nurses perform this on every admission and transfer.
What is a skin assessment?
This medical device that redistributes or relieves pressure on the body to reduce the risk of developing pressure injuries.
What is an air mattress?