Wound Dressings
Provides absorption of exudates, can help debride wounds, and is often used for cleaning of packing wounds.
Gauze
The separation and disruption of previously joined wound edges that usually happens when the primary healing site bursts open.
Dehiscence
What kind of pressure injury is characterized by non-blanchable erythema of intact skin?
Stage 1
What is the largest organ of the human body?
The skin!
What service is responsible for providing specialty care to patients at NIH with wounds, ostomies, and incontinence base skin issues?
WOCN (Wound and Ostomy Care Nurses)
A dressing made of foamed polymer solutions with small, open cells that can absorb a moderate to heavy amount of exudate.
Foams (aka Mepilex)
An abnormal internal or external blood loss that can be caused by infection, a blood clot, or erosion of a blood vessel from something like the tubing of a drain.
Hemorrhage
What stage is characterized by partial thickness skin loss and exposure of some dermis?
Stage 2
When do we do a skin assessment on patients?
On admission, on every transfer from other units, and every day!
Whats the name of the unit representative who participates in quarterly Pressure Injury Prevention survey?
SWAT (Skin Wound Action Team) member
A dressing that can be in sheet, gel, or gauze form that is able to provide a moist healing environment to a dry wound bed.
Hydrogel (AquaSite, Saf-Gel, etc)
Wound edges that separate enough to expose part of the intestines through the wound.
Evisceration
What stage features full thickness skin loss with adipose tissue and granulation tissue visible and often has tunneling or undermining present?
Stage 3
What tool do we use to assess and predict a patients risk for skin breakdown?
The BRADEN scale
Who is responsible for assessing patients for skin breakdown and placing Wound Care consults?
Clinical Research Nurse (CRN)
Transparent semipermeable membrane dressing that permits gaseous exchange between the wound and the environment.
Transparent films (Tegaderm, etc)
Bands of scar tissue that form between or around organs.
Adhesions
What stage features full thickness skin loss with exposed fascia, tendon, muscle, ligament, cartilage, and/or bone?
Stage 4
What number on the Braden scale triggers an alert to get a Wound Care Consult?
18 or less!
Who helps promote pressure injury initiatives on the unit and discusses any new issues with staff at huddle?
Unit leadership and the unit educator
Wound dressings that deliver agents such as iodine, silver, or polyhexamethylene biguanide (PHMB) that have antibacterial properties to help partial or full thickness wounds.
Antimicrobials (I.e. Biopatch, SilverDerm)
A protrusion of scar tissue that extends beyond wound edges and may form tumor like masses of scar tissue around a wound.
Keloid formation
What stage would a wound be that is covered by slough and eschar?
Unstageable pressure injury
What additional tool should we be doing daily to assess a patient for any potential skin or mucosal injuries?
Beck’s Oral Assessment
Who participates in a RCA (Root Cause Analysis) when a pressure injury is found on the unit?
All members of the patient care team!