Pressure Ulcers

Risk Factors

100

Name three risk factors for developing pressure ulcers

What is obesity, poor nutrition, prior skin ulcers, dehydration sensory impairment, smoking

200

Greatest risk factor for the pressure ulcer development

What is Immobility

300

Immobility for what time frame can cause tissue ischemia?

What is 20 minutes?

400

Occurs when internal body structures and skin tissues move in opposite directions.

What is shearing?

500

A Braden scale score of this means the resident is "at risk"

What is 18 or less?

Miscellaneous

100

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?

200

Pressure injuries commonly form over?

What are bony prominences?

300

The Larsen Health Center consults wound care consult for which pressure injuries?

What are Stage III, IV, and Unstageable?

400

How many Braden Scale categories are there?

What are 6?

500

The force that occurs when two surfaces rub together.

What is friction?

Stages

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

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

300

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

What is Stage 4

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

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

Prevention

100

This should be performed every two hours for "at risk" residents.

What is turn and reposition?

200

What is a device that can be used to offload pressure?

What is air mattress, heel lifts, wedges, pillows

300

This food group is extremely beneficial when a wound present.

What is protein?

400

What blood work should be assessed to determine nutritional status?

What pre albumin level?

500

This should be done with every admission and transfer with two nurses.

What is a skin assessment?

Prevention 2

100

A set of predetermined orders for wound care.

What are nurse-driven order sets?

200

Patient's at nutritional risk should have what ordered?

What is a dietary consult?

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

What is the main difference between a Stage I and Stage II?

What is a break in skin?

500

What device should be used on patients and checked daily for proper use?

What is air matress