Prevention
A&P
Risk Factors
Documentation
Staging
100
Three ways to prevent pressure injuries
What is any of the following: Repositioning/Offloading Incontinence care Microclimate management Pressure relief devices Adequate nutrition Skin checks at least every shift Minimize friction and shear
100
The body's first line of defense
What is the skin? (Intact skin keeps out micro-organisms)
100
Three factors that put a patient at risk for a pressure injury
What is Incontinence, Immobility, Acute illness, History of previous pressure injury, Poor nutrition, Edema, Medical devices, Comorbidities
100
Turning/repositioning/offloading heels should occur ____ hours and is documented every time in ____.
What is at least every 2 hours and in Iview.
100
"Hyperpigmented" African American skin painful area to sacrum with peeling skin revealing ruddy red base.
What is an evolving deep tissue injury?
200
An inpatients skin should be assessed at this frequency
What is on admission (4 eyes in 4 hours), at least every shift and upon change in condition
200
Name two areas of the body that are at highest risk for pressure injury
What is the sacrococcygeal region and the heels?
200
Three sources of moisture that can damage the skin
What is incontinence of urine/stool, perspiration, weeping skin and wound drainage?
200
Wounds and pressure injury measurements are documented this frequently in Iview.
What is upon admission, every Tuesday, when wound characteristics change and on discharge.
200
An intact fluid filled blister on the heel.
What is a stage 2 pressure injury?
300

Changes in skin color and/or temperature, painful area, microclimate (moisture/heat), boggy skin, open areas.

What are things to look for when assessing skin?
300
The first signs/symptoms of a pressure injury.
What is persistent non blanching redness and pain, even after pressure has been relieved?
300
All pressure injuries are avoidable (T/F)
What is false?
300

This paints an accurate picture of what's going on with the patient, supports the interventions your doing, keeps you out of legal trouble

What is good documentation?

300
Stage 3 pressure injury.
What is full thickness loss of skin, adipose tissue and granulation tissue often present, slough/eschar may be present, depth varies by anatomical location, undermining and tunneling may occur?
400
If a patient's legs are flattening out pillows which are meant to offload, this is a beneficial alternative
What is Heel Medix boot?
400
The difference between a stage 2 and stage 3 pressure injury

What is partial vs full thickness.

Stage 2-partial thickness with exposed dermis-NO SLOUGH Stage 3- full thickness, may or may not have slough, undermining or tunneling.

400
Patients at risk for heel pressure injury (name 2 conditions/co morbidities)
What are diabetic patients, patients with neuropathy, joint replacement, paralysis and limited mobility?
400
Skin tears, diabetic wounds, leg ulcers
What is documented in IView under WOUND information?
400
Wound under an ET tube inside the lip
What is a mucosal pressure injury and Medical Device Related Pressure Injury
500

Strain on the skin, when its layers are laterally shifted in relation to each other.

What is shear?
500
A wound under a medical device that mimics the shape of the device.
What is a Medical Device Related Pressure Injury?
500
Low blood pressure, increased body temperature, multiple co morbidities
What is an increased risk for pressure injuries?
500
Tool utilized for proper Hospital Acquired Pressure Injury (not part of the medical record)
What is the Pressure Injury Checklist?
500
A blood filled blister to the coccyx on a bedbound patient
What is a deep tissue pressure injury?
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