Skin Assessment
Skin Assessments should be completed
What is on admission/transfer, every shift and with any changes
TRUE/FALSE: Always massage reddened skin or bony prominence's.
What is False?
A skin risk assessment should be documented
What is on admission/transfer, every shift, and with any changes.
For patients with poor food intake this should be encouraged.
What is liquid nutritional supplements?
Immobile patients should be turned
What is every 2 hours
List 2 items the nurse should assess to determine pressure injury risk and skin condition on admission and every shift.
What is skin compromise at bony prominences, urinary and fecal incontinence, physical immobility, etc.?
To prevent skin breakdown the number of layers under the patient should be
limited/ least amount possible.
No more than 2 layers
When turning a patient the you should assess
What is bony prominence's?
A consult should be placed to this department to assess the patients protein intake
What is nutrition?
Devices should be used to _______ pressure on heels.
Offload or relieve
When a patient is admitted with dressed wounds the nurse must...
What is remove the dressings to assess the wound?
Assistive devices can be used to maintain correct body position and prevent complications when patients must be on
What is prolonged bed rest?
This person should assess a patient with a wound within the first 48 hours of admission
What is wound care?
Make sure a consult is placed.
Does vitamin C help prevent pressure injuries?
There is not enough evidence to support this.
When moving patients in bed it is important to avoid dragging or pulling to prevent _____ injury.
What is shearing or tearing?
All pressure injuries discovered on admission/or assessment will be documented and reported to ...
What is the physician?
These dressings may be used to prevent shear before a wound has developed
What is soft silicone foam or extra thin hydro-colloid?
This percentage of pressure injuries is thought to be preventable.
What is 95%?
The nurse should monitor for changes in _____ , which can be an indication of malnutrition and pressure injury risk.
What is Serum Albumin?
True or False: When a patient is on a specialty mattress you no longer have to turn them every 2 hours.
What is false?
Nurses should verify these 3 orders are placed for patients with wounds
What is wound care consult, nutrition consult, and a specialty bed?
Studies show that soft silicone or foam dressings decrease the incidence of pressure injuries by what percent?
What is 79%
List 5 items that increase the risk of developing a pressure injury
What is: older age, impaired mobility, poor nutrition, inactivity, friction and shear, dehydration, incontinence, cognitive impairment, medical conditions (DM, PVD, stroke, spinal cord injury), smoking, hip fracture, etc.
When caring for incontinent patients list 3 things you can do to prevent skin breakdown.
What is inspect the skin frequently, apply a topical skin barrier cream, cleanse the skin after each episode of incontinence, use noncytotoxic cleansers, etc.
The head of the bed must be maintained at the _____ degree of elevation to prevent pressure, sliding, and shearing on the sacrum.
Lowest possible or at least 30 degrees. Unless contraindicated