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
List three ways to prevent
pressure ulcers.
Repositioning
Incontinence care
Toileting schedules
Pressure relief devices
Adequate nutrition
Skin inspections weekly
Use of moisturizing lotion and/or barrier creams
Avoid friction/shearing
100
Name 3 sources of moisture that can damage the skin
Incontinence of urine and/or stool
Perspiration
Wound drainage
200
Greatest risk factor for the pressure ulcer development.
What is Immobility
200
How often should an at-risk resident’s skin be inspected for breakdown?
at least daily and more frequant based on the patient clinical condition
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
Name 3 areas on the body where pressure ulcers are most likely to occur.
Bony prominences: back of? head, ears, shoulders, spine,? hips, coccyx/sacrum, inner/outer? ankles, heels, toes, sides of feet.
Areas that rub: casts, prosthesis.
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
What do you look/feel for when inspecting a resident’s skin?
Changes in skin color and/or temperature
Open areas or abrasions
Mushy/boggy area
Area painful to touch
300
Full thickness skin loss with extensive destructin, tissure necrosis, or damage involving muscle.
What is Stage 4
300
What is the difference between a stage II and a stage III pressure ulcer?
Stage II – partial thickness skin loss,, superficial, presents as an abrasion, blister, or shallow crater?
Stage III – full thickness loss involving subcutaneous tissue, may extend down to, but not through, underlying fascia?
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
how the nurse reports when a patient has a pressure ulcer
OVR ,Infection control
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
"true or false "
The head-to-toe skin inspection should be documented there is no need to mention clear identification of pressure ulcer presence or absence on assessment.
false
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
List 3 things that put a resident at risk for developing a ?pressure ulcer
Restraints
Incontinence
Immobility
Acute illness
History of pressure ulcers
Poor nutrition
Certain medical diagnosis/meds
Weight loss
Obesity
Cognitive impairment
Edema
500
What device should be used on patients and checked daily for proper use?