Staging
The NPUAP pressure injury staging system can only be used for this type of wound.
What are pressure injuries? Only pressure injuries should be staged with the NPUAP Pressure Injury Staging System. Non–pressure-related ulcers and wounds are subject to unique staging or classification systems based upon wound type: diabetic foot ulcers (Wagner Classification System), venous leg ulcers (Clinical, Etiology, Anatomy, Pathophysiology), skin tears (International Skin Tear Advisory Panel), adhesive or tape injuries (Medical Adhesive Related Skin Injury categories, MARSI), and burn classification (total body surface area).
This wound type often leads to osteomyelitis and lower limb loss.
What is a diabetic foot ulcer?
A patient at risk for pressure injuries should be repositioned this frequently while in bed.
What is every 2 hours?
The number one and most researched tool for the risk of developing a pressure injury.
What is the Braden scale?
Three roles of dressings.
What are Protection, Promote Healing, Contain Drainage, Maintain Temperature, Provide Moist Wound Environment, and Antimicrobial Treatment?
The Stage assigned for a clear blister over a heel caused by resting in the bed.
What is a Stage 2 pressure injury?
A heavily draining ulcer on the side of an edematous, hemosiderin stained leg is caused by this.
What is venous insufficiency?
This is the best device available here for inpatient seating for pressure relief .
What is the EHOB Waffle cushion?
Under the Moisture category, a patient that is occasionally incontinent of urine will get this numerical score.
What is 3?
These topical treatments are outdated and no longer considered evidence based practice.
What are NS wet-to-dry; Silvadene; open to air; tid dressing changes; betadine (except for arterial ulcers), hydrogen peroxide, TED stockings.
One way to differentiate between moisture associated skin damage and pressure injury.
What is location? incontinence? pattern? progression?
The proper treatment for a large skin tear
What is Mepitel One and a dry dressing left in place for several days?
Name a device that may cause a pressure injury.
What are shoes, oxygen tubing, Foley tubing, bedpans, urinals, casts, Bipap masks, ET tube holders, TED hose?
When a patient cannot have the HOB below 30 degrees, there is an increase in these 2 pressure injury contributing factors.
What are Friction and Shear?
The name of a super absorbent dressing.
What is Mextra?
A black eschar on a heel and the dorsal toes of a foot without a palpable pulse is most likely this etiology.
What is peripheral arterial insufficiency? or PAD?
The name of powered NPWT delivery system at the Martinsburg VA and the name of non-powered NPWT delivery system at the Martinsburg VA
What are wound VAC and SNAP?
This is the most important thing to do when a patient refuses to reposition.
What is document?
A paraplegic patient will get this score under Sensory Perception.
What is 1?
Two contraindications for NPWT.
What are cancer in or around a wound; lack of hemostasis; vessel, bone, tendon exposure; untreated infection; necrotic tissue in the wound?
It is important to document present on admission pressure injuries for these reasons.
What are HAPIs are monitored by the VA, JACHO, LTCI, Medicare and other agencies; It is a Nursing Quality Measure; Litigation; Proper prevention measures; and patient comfort?
When an abdominal surgical wound suddenly comes apart, what is the first treatment?
What is a moist, supportive wound dressing?
The seated patient most often develops a pressure injury over this bony prominence.
What is the ischium?
The Braden scale is useful only when it leads to this.
What are pressure injury prevention interventions?
This is an important component of doing a dressing change.
What are handwashing; pain control; cleansing; and clean technique?