Stages
Intact skin with a localized area of non-blanchable erythema.
What is a Stage I pressure injury
The scale used to determine the risk of Pressure Injury
What is Braden Scale?
Most clinicians use the _____ rather than the palm of their hand to assess the temperature of a patient's skin.
What is the back?
When applying oxygen, check the ______for pressure areas from the tubing.
What are the ears?
Partial thickness loss with exposed dermis
What is a Stage II Pressure Injury?
The ability to respond to pressure related to discomfort
What is sensory perception?
Compare ________________body parts for differences in skin temperature.
What is symmetrical?
Each time you provide care, look at the exposed skin, especially on ______ prominences.
What is bony?
Persistant, non-blanchable deep red, maroon, purple discoloration.
What is a Deep Tissue Injury - Unstageable
Expert opinion has traditionally advised repositioning every ____ hours
What is two?
Know the person's ________skin tone so that you can evaluate changes.
What is baseline or usual or normal
Pressure injuries are associated with longer hospital stays and increased morbidity and ____________
What is mortality?
Full thickness loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone
What is a Stage IV Pressure Injury?
Most pressure ulcers develop over bony prominences, typically the sacrum and _______
What are the heels?
Depress any discolored areas to see if the skin is blanchable or __________________
What is nonblanchable?
One should shift weight in a wheelchair every __________ minutes
What is 15 to 20
Full thickness tissue loss of skin, adipose (fat) is visible in the ulcer and granulation tissue is often present
What is Stage III Pressure Injury.
____________ skin checks should occur. Any areas of new skin injury must be reported following the chain of command.
What is daily?
To assess skin turgor, take your fingers and "pinch" the skin near the clavicle or the forearm so that the skin lifts up from the underlying structure. Then let the skin go.
What is tenting?
When lying on one's side, Nursing staff should place a ______________between the resident's knees and ankles.
What is a pillow?