Name the Stage
Intact skin. Non-blanchable. Erythema is present.
What is a Stage 1 pressure injury?
How often patients should be turned and repositioned
What should occur every 2 hours?
True or False: Bony prominences like elbows, heels, sacrum, scapula, spinous processes, hips, are more prone to pressure injuries
What is True
Heels, elbows, hips can be floated off the bed by using
What are Pillows
The result of intense, prolonged pressure. Localized damage to skin and underlying soft tissue over bony prominences, or related to medical devices
What is a pressure injury?
Full thickness skin and tissue loss. Wound base is obscured by slough or eschar.
What is an unstageable pressure injury?
Skin assessments occur
What is upon admission, at least once a shift, with change in condition, upon transfer
What factors should be included when assessing a patients skin?
Scale that is used to assess risk for pressure injury
What is the Braden scale
Dietary measure to promote wound healing
Diet high in protein
May be intact or non-intact skin. Non-blanchable, deep red, maroon or purple discoloration. May be a blood filled blister.
What is a Deep Tissue Injury?
Patients with pressure injuries and or wounds should receive consults to see
what is Nutrition & Wound Care specialists
Name 3 extrinsic factors that lead to pressure injury development
What are moisture, shear and friction
Devices that place a patient at a higher risk of pressure injuries
Nasal cannulas/O2 devices, IV tubing/lines, urinary catheters, bedpans
A condition caused by prolonged exposure to sweat, urine, and or feces
What is moisture associated skin damage
Full thickness skin loss. Granulation tissue is seen. Slough and eschar may be present. No muscle or bone exposed.
What is a Stage 3 pressure injury?
In addition to completing the Braden scale to achieve a risk score for patients developing pressure injuries, these risk factors should also be considered
What are nutritional status, previous pressure injuries, hydration status, perfusion and oxygenation, age
What is persistent non-blanchable erythema after pressure has been relieved?
Pressure injuries place the patient at a higher risk of
What is additional pressure injuries, longer hospitalization, and mortality
Medical term for describing dead tissue
What is necrotic, necrosis
Full thickness loss of skin and tissue. Tunneling and undermining may be present. Exposed tendon, muscle, bone, or ligament.
What is a Stage 4 pressure injury?
Interventions the nurse can implement to protect patients skin and avoid friction/shear from occuring
What are keeping the bed linens clean, dry and wrinkle free, apply transparent/foam dressings over boney prominences, avoid pulling patients from side to side, frequent repositioning, avoid massaging
What is partial vs full thickness skin loss.
Medical conditions that increase the risk of developing pressure injuries
What are diabetes, neuropathy, paralysis, obesity, malnutrition
Measurement (length, width, depth), color, drainage, odor, stage, location
What is appropriate documentation of a wound/pressure injury?