Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.
What is a pressure ulcer?
100
This should be documented at the time of admission and every 12 hours.
What is a full skin assessment?
100
A pressure ulcer risk assessment completed on hospital admission, every 12 hours, and with each change in condition.
What is the Braden Scale?
100
Name 2 instances when a pressure ulcer wound dressing should be changed.
What is when visibly soiled, at the time of admission, per physician orders, or per patient request?
100
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous-filled blister.
What is a Stage II ulcer?
200
Process by which the hospital determines the Prevalence and Incidence of pressure ulcers in the hospital.
What is a prevalence and incidence study (P&I)?
200
The scale used to evaluate pressure ulcer risk.
What is the Braden Scale?
200
The Wound and Ostomy Nursing Consult service documents here.
What is the Consults tab under the Note activity button?
200
This is a dry, black area on a pressure ulcer that often impairs staging of pressure ulcers.
What is Eschar?
200
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling
What is a Stage IV pressure ulcer?
300
Pressure ulcers can develop on any skin surface subject to excess pressure such as under oxygen tubing, drainage tubing, casts, cervical collars or other medical devices.
What is a device related pressure ulcer?
300
The minimum amount of time for turning patients at risk for pressure ulcers.
What is 2 hours?
300
These are the four components of a basic skin assessment.
What are skin color, skin temperature, skin condition, and turgor?
300
An inexpensive, efficient technique used by nursing staff every 2 hours to reduce the incidence of pressure ulcers.
What is turning and repositioning?
300
Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
What is an unstageable pressure ulcer?
400
This occurs when one layer of tissue slides horizontally over another, deforming adipose and muscle tissue, and disrupting blood flow.
What is shear?
400
Name 2 interventions to prevent pressure ulcers.
What is mositure management, adequate nutirtion, frequent reporsitioning, pressure redistribution surface, ambulation?
400
This should be completed for HAPU Stage II or greater.
What is a Wound and Ostomy Nursing Consult Service consult and an SI Event Report?
400
Nurses should encourage patients to stop this activity to help improve the amount of functional hemoglobin/oxygen carrying capacity of the blood to all areas of the body prone to breakdown.
What is smoking?
400
Related to the loss of protective sensation in the feet and legs, usually located on weight bearing surfaces including the plantar surface of the foot and heel with or without undermining.
What is a neuropathic (diabetic) foot ulcer
500
The force that is applied vertically or perpendicular to the surface of the skin. It compresses underlying tissue and small blood vessels hindering blood flow and nutrient supply.
What is pressure?
500
Evidence-based strategy to improve overall patient safety and quality outcomes.
What is intentional rounding?
500
The place to document removal of pressure ulcers from previous hospital admissions.
What is the LDA removal section of the ADT navigator?
500
The writing you should see on each wound dressing to communicate when the dressing was last changed.
What is the date, time and initials of the person changing the wound dressing.
500
Often misidentified as a Stage II; this wound is characterized by inflammation, occurring with or without erosion or secondary cutaneous infection.