Pressure Ulcer Stages
I am the first choice topical tx that can be applied with "nursing judgment" in an incontinent pt. I go on clear so can easily see/inspect the skin through a thin layer of application.
Skin barrier ointment or Cavilon no sting barrier film
What does V.A.C. stand for?
vacuum assisted closure
The three most common types of ostomies seen here are:
What is an ileostomy, a colostomy or an ileal conduit (urostomy).
What scenarios require a 2nd RN witnessed skin check?
Admission, unit transfer and discharge
It is okay to leave on a diaper or pull-up during the night or when sitting in the chair for an incontinent patient... true or false?
False - these products trap heat and are caustic which will speed up skin breakdown. Use of absorbent chux while allowing the skin to breathe is the best course.
What is an alternative name for wound vac treatment?
Negative pressure wound therapy (NPWT)
How big should the opening of the pouch be cut?
As close to the size of the stoma as possible. Templates may be available at bedside, but otherwise estimate to the best of your ability to protect peristomal skin.
I am initiated when Braden score is less than 18 or patient develops a skin injury.
IPOC - Risk for or actual impaired skin integrity
Patient is incontinent of B&B and is admitted with a st. 2 pressure injury to the coccyx. He requires cleaning multiple times a shift. You come on shift in the evening and notice a mepilex dressing was placed on the open lesion. What do you do?
Remove the mepilex and switch treatment to skin barrier ointment or Cavilon no sting barrier film. Use of mepilex in this case is a waste of materials and will trap soiling that could cause infection.
Scenario: Surgeon calls you to say they are coming to bedside to place a wound vac. You need to order supplies to be ready for them. What do you order?
Place order for vac in Cerner (CSP Info Vac); order 500 cc canister and black or silver foam from R&D; grab gauze, wound cleanser and suture removal kit for bedside.
If an ostomy pouch is leaking from the seal, it is okay to tape the borders to reinforce it... true or false?
False - you should never tape an ostomy pouch because the leak will continue underneath the tape and cause skin irritation and damage due to the acidic content of the output. If a patient complains of itching under the barrier this is a good indication that there is a leak and it needs to be changed.
This is done every Wednesday and placed in the chart.
Photo day! All pressure injuries should be documented weekly via photo and the photo placed in the chart. Wound measurements should be taken and documented at the same time on this day.
I am a treatment that is commonly prescribed for wounds that contain slough. My main job is enzymatic debridement (getting rid of the slough). I come from pharmacy and am expensive - so please use me correctly! I am applied nickel-thick and typically changed every day.
What is Santyl (collagenase) ointment
Patient has a wound vac to their RLE following a trauma, and is set to go home tomorrow with continued NPWT. Name next steps...
Confirm with DCP whether home vac is ordered from surgeon. When it arrives at the bedside - plug in to charge. Open a new canister and attach to vac. Switch over to home vac right before patient is set to go home.
Patient is admitted on the weekend with an urostomy. Their pouch needs to be changed upon admission, but you express disappointment that pouches are only changed by the wound ostomy nurses during the week. True or false?
False - unless it's a new post op ostomy, the pouch can be managed by nursing staff. Especially if bag is leaking, do not wait for wound ostomy nurses to change.
When auditing pressure related injuries that have occurred - there is a specific area in IView that should reflect any preventative measures.
"Activities of Daily Living" section- Turning and repositioning documentation should reflect ACTUAL work done. Can be documented by PCA or RN (whoever does it), but repositioning ultimately is the responsibility of the nurse.
Scenario: Admitting 82 y.o. female from SNF for pneumonia. PMHx of CVA w. residual R hemiplegia, dysphagia w. g-tube, incontinent of b&b, DM, HTN and bedbound. What skin integrity prevention measures will you implement immediately?
Routine offloading (q2hrs) with foam wedges, incontinence plan (chux, purewick, skin barrier ointment), initiate risk for skin impairment IPOC, and possibly order low air loss mattress
VAC has been alarming on/off the first 4 hours of night shift saying "leak". You don't see an opening but the foam is expanded. What do you do?
It has been longer than 2 hours and patient is at risk for infection. Page SIOC and have supplies ready for wound vac change. Remove the vac and place wet-to-dry dressing in the meantime.
These products are to be used if peristomal skin is raw.
Ostomy powder and Cavilon no sting barrier film. To be applied in that order after cleaning skin with moist gauze and pat dry.
Scenario: your patient who has been here for 4 days has developed a stage 2 to the coccyx. When going to "incision & wound" there is no section opened for coccyx but one for sacrum exists with all the description of the presumed st 2. You continue documenting in this area as well - true or false.
False - the coccyx is not the sacrum. We must document accurately. Close the section on sacrum and open a new tap for coccyx - properly documenting the stage 2 PI.