Risk Factors
Name 2 risk factors for pressure ulcer formation
Pressure, shear, malnutrition, immobility, Age, Incontinence
What's Bundle is used in the Bon secours for pressure ulcer prevention care?
SSKIN Bundle
Partial thickness skin loss involving epidermis and/or dermis, the ulcer is superficial presenting as a abrasion, blister, or shallow crater
Stage 2 pressure ulcer
Used on patients chair for those at risk of pressure ulcer or with active ulcer to sacrum
chair cushion (pressure redistribution cushion)
What can be used to off-load pressure from the heels?
Pillows or off-loading boots
Greatest risk factor for pressure ulcer development?
Immobility
10 and greater
Non-blanching erythema (nil tissue loss)
Stage 1 pressure ulcer
What product is used on patients skin if incontinent of urine or stool
Skin Barrier (e.g Cavillon, zinc oxide)
What nutritional screening tool is used in the Bons Secours
MUST
This scale is utilized to assess patient's risk factor for pressure ulcers?
Waterlow
A skin assessment is completed in the Bon secours within how many hours of admission?
Within 6 hours of admission
Full thickness skin loss with extensive destructin, tissue necrosis, or damage involving muscle.
Stage 4
This product helps prevent friction/shear damage to sacral tissue
sacral foam
Patients at nutritional risk or with an active ulcer should be offered this
A dietician consult
What parallel frictional force that occurs as patients are dragged during repositioning as opposed to being lifted and moved?
Shearing
Who should be notified if a new pressure ulcer identified on your unit?
Unit manager, NQ and TVN
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not throught, underlying fascia.
Stage 3
What's is the no.1 thing you can do as a nurse to prevent pressure ulcers
Regular repositioning
Donut shaped rings/cushions help prevent pressure ulcers?
False (increases further ischemia if used and should not be used)
What time frame can cause tissue ischemia if correct risk factors present?
20 minutes
What chart is opened and documented on when a pressure ulcer is identified?
Wound assessment chart
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.
Suspected deep tissue injury/pressure ulcer
What degrees side lying position is recommended for pressure ulcer prevention?
30 degrees side lying position
What device should be ordered for a patient when unable to reposition themselves
Alternating air mattress