Stage That Wound
Dressings
Documentation
Odds 'N Ends
Name That Wound
100

An area of non-blanchable erythema over a bony prominence.

What is a Stage I pressure ulcer?

100
Vaseline Gauze or Adaptic, dry gauze, Kerlix, daily
What is the typical dressing for a Skin Tear
100

A risk assessment completed on hospital admission, every shift, and with each change in condition.

What is the Braden Scale?

100

How do you get ahold of wound care?

What is, Tiger Text, place a wound consult for non urgent wounds, or call the wound care phone?

100
A partial or full thickness wound in which a flap may or may not be present
What is a skin tear
200
A shallow open area, over a bony prominence, involving the epidermis and dermis
What is a Stage II pressure ulcer
200

Can be changed every 5-7 days, harsh on the skin, handles small to scant drainage, appropriate (but not the best choice) for Stage I and II pressure ulcers on the coccyx/sacrum

What is a Hydrocolloid

200

How do you take a picture of a wound, and upload it to the chart?

What is using a CareAware phone camera App to take a picture. 

The picture should include the wound, a wound ruler with measurements and patient information. Date, time, and initials should also be written on the ruler. The photo should be named describing the location of the wound.

200
White soft tissue surrounding a wound
What is Maceration Tissue
200
Erythema and inflammation of the buttocks which may or may not lead to open lesions
What is Incontinence Associated Dermatitis
300
An unopened, dry, boggy, purple, nonblanchable area on a bony prominence
What is a Deep Tissue Injury
300

This dressing should never be placed on a Skin Tear

What is an adhesive dressing such as Tegaderm?

300

What documentation do you do if you find a suspected pressure ulcer? Must name 5/6 steps.

What is take a picture and upload it, document the wound with measurements in Cerner, notify the provider, place a wound consult, activate Pressure Injury IPOC, place Midas.

300
This skin problem appears as superficial peeling of tissue as it resolves
What is Candidasis or Yeast
300

A wound resulting from compromised blood flow to tissue that can take months to heal.

What is an arterial ulcer. 

400

A pressure injury covered with sough or eschar.

What is an unstagable pressure injury?

400
An alternative to a dressing which can be placed over Stage I pressure ulcers, intact skin at risk for breakdown, and Deep Tissue Injuries which have not progressed to eschar
What is 3M No Sting Barrier Film wipe/spray
400

What Braden score is the minimum threshold for pressure injury prevention interventions?

What is 14?

400
The rate of hospital-acquired pressure ulcers measured at a specific point in time
What is prevalence
400
A dry wound typically located on the plantar foot or toes that is surrounded by hyperkeratotic tissue (callus)
What is a neuropathic (diabetic) foot ulcer
500

A pressure injury extending through the sub-q tissue, exposing tendon and bone. 

What is a stage 4 pressure injury?

500

Can be changed every 5-7 days, gentle on the skin, handles moderate to large drainage, third-spaces drainage away from the skin and is the preferred dressing for Stage II pressure ulcers on the coccyx/sacrum

What is a foam dressing?

500

Name all three instances that you must document a 4-eyes assessment.

What is on admission with 4 hours of arrival, transfer to another unit, and after prolonged surgery of 4 hours or more?

500

Name five pressure injury prevention interventions.

What are:

1.Q2 turns
2.Offloading heals and elbows
3.HOB <30 degrees (unless contraindicated)
4. Waffle Mattress overlay
5. Specialty bed
6. Wound consult
7. Single layer breathable pads
8. Lift or slide equipment to avoid shearing
9. Nutrition consult
10. Manage Moisture/incontinence (barrier cream)
11. Mepilex

500

A shallow wound, typically on the lower leg, which is irregular in shape and moist. These wounds are painful.

What is a venous insufficiency ulcer

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