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?
Braden scale is done upon admission and every 24 hrs on inpatient and observation patients (ad hoc)
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
The RN documents on this form to demonstrate what you doing to PREVENT skin breakdown.
What is the Skin maintenance protocol
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 EPC (extra protective cream)
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
Updated minimally every 24 hours for plans to manage issues with skin
What is the careplan
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
Wound Nurse, Physician, Nutrition, Patient
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 should not be used in skin 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
Document here to capture costs in equipment used to manage skin and wound
Braden to document beds and rental beds
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
Skin maintenance protocol task will fire with this score
What is a score of 16-18
500
What device should be used on patients and checked daily for proper use?