PI General Knowledge
Areas include: sacrum, heels, ankles, elbows and occiput.
What is a bony prominence?
When urine or faeces have prolonged contact with the skin over-hydration occurs leading to skin breakdown.
What is Incontinence Associated Dermatitis?
Completed upon identification of a wound and repeated with each wound dressing.
What is a wound chart?
Pressure injury prevention for the bridge of nose when using BIPAP.
What is a Gecko Pad?
All patients are to be screened for pressure injury risk on admission, once per shift and with change in condition using this score.
What is a Braden Score?
Non-blanchable errythema
What is a stage 1 pressure injury
Commonly occurs between skin folds and is characterised by moist erythema, malodour, weeping, pruritus and tenderness
What is Intertigenous Dermatitis?
With consent, capture the wound at the centre with a ruler for scale and the patient addressograph.
How do you take a photo of a wound?
Changed daily during patient wash.
What is an ECG dot?
Identifies strategies for preventing pressure injury and includes quick links to Skin Assessment, Wound Care Chart and Scheduled Tasks available.
What is the Pressure Injury Prevention Plan?
Full thickness tissue loss in which the base of the PI is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the PI bed. Until enough slough/eschar is removed to expose the base of the PI, the true depth, and therefore the stage, cannot be determined.
What is an unstageable pressure injury?
Impregnated with 3% dimethicone to cleanse, moisturise and provide a barrier for the skin against moisture.
What is a Shield Barrier wipe?
PI identified at this stage or greater require referrals need to be made to the : Dietician, Occupational Therapist and Wound Care CNC
What is a Stage 3 Pressure Injury?
Floats the heel off the mattress to relieve pressure. The soft, adjustable straps position the foot and ankle securely, leaving the toes and heel exposed.
What is a Prevalon boot?
A versatile five-layer all-in-one bordered foam dressing that is clinically proven to help prevent pressure ulcers when used in conjunction with standard pressure ulcer prevention measures.
What is a 5-layer Mepilex Boarder?
Purple or maroon localised area or discoloured, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed or occur as a result of shearing or friction forces.
What is a suspected deep tissue pressure area?
When used as a pre-op wash, effective against gram-positive organisms, particularly staphylococcus aureus, and gram-negative organisms. Has little activity against pseudomonas, yeasts or fungi. When used correctly, reduces the number of normal skin flora.
What is Triclosan 1%?
Irrigate well with saline, wait 1 minute, swab the healthiest looking tissue in the wound bed and send for culture.
What is the 'Levine' wound swab method?
This system is designed to stay under the patient at all times so it’s always ready to assist with turning, repositioning, and boosting the patient
What is a TAPs system?
Strategies include: maintaining adequate nutrition, repositioning patient every two hours, ensuring no IV lines or leads are under the patient, using comfy ears, gecko pads, 5-layer mepilex boarders, the TAPS system and Prevalon boots.
What is pressure injury prevention?
The device that causes the highest number of device related mucosal and pressure injuries for St George ICU.
What is an endotracheal tube?
Term that refers to the temperature and moisture of the skin.
Increases in skin temperature accelerates pressure induced skin damage risk for hospitalised patients. These cellular changes result in skin maceration and damage.
What is microclimate?
Do not require reporting within the IIMS system, but should be recorded in other clinical documentation such as the clinical notes, wound care chart, skin assessment form and pressure injury prevention management plan.
What is a non-hospital acquired pressure injury?
Endotracheal tubes, nasogastric tubes, TED's and nasal cannulae.
What are STG ICU's highest cause of medical device associated pressure injuries?
Generating small shifts or position changes by distributing the pressure at the patient’s head, shoulder, hip or thigh. It allows positioning changes quickly and gently without moving the patient.
What is micropositioning?