Staging
This full thickness wound is obscured by slough or eschar
What is An Unstageable pressure injury
Nurses must complete this skin assessment process within four hours of admission
What is "4 eyes in 4 hours"
This component of MAPP includes documenting wound measurements such as length, width and depth
What is measure?
This wound type develops when pressure cuts off blood supply to tissue from either something pushing in or something pushing out
What is a pressure injury
A patient at high risk for a sacral pressure spends most of the day in the chair. His heels are reddened. These support surfaces are needed for prevention
What is a specialty bed, a waffle cushion, Z Flex boots and the tortoise system
This injury has purple or maroon discoloration or is a blood filled blister
What is a deep tissue pressure injury (DTI)
These 3 Braden subscales are remembered as the MNMs
What are Moisture, Nutrition, and Mobility?
A newly identified pressure injury requires these 4 actions before treatment recommendations are selected
What are Measure, Assess, Photo, and Plan
This wound must be staged and documented within the first 24 hours of admission
What is a present on admission wound (POA) or pre-existing wound
Hyperglycemia, poor nutrition, dehydration, and infection are examples of these factors that can slow or prevent wound healing
What are barriers that prevent wound healing
Grey tubing and Mepilex lite are commonly used to prevent injuries from these
What are medical devices (name a few)
A Braden subscale of 1 or 2 should cause nurses to ask this important question
" What did you DO"?
This must be completed for all wounds upon discovery and placed in the flowsheet and on the LDA
What is taking a wound photo
Unlike pressure injuries these wounds are not classified using staging methods
What are surgical wounds, arterial, venous, & diabetic ulcers or skin tears
These 4 phases make up the wound healing process
What is Hemostasis, inflammation, Proliferation, and remodeling
A stage 4 can heal into a stage 3
What is FALSE
A patient is admitted with a blanchable red area on her sacrum, a Braden score of 15 and is continent at this time. Mositure-3, Nutrition-3, Mobility-2. These interventions are needed
What is a preventative sacral dsg, specialty bed, heels elevated, turn and positioning
Pressure injuries should be fully MAPPED on admission or discovery and on this weekly event
What is wound Wednesday
While helping a patient transfer to a chair, the nurse notices a flap of skin partially separated on the forearm. This wound can be identified as what?
What is a skin tear
A patient with frequent urinary incontinence has diffuse redness on the buttocks and sacral area. The skin is painful but does not appear over a boney prominence. Prevention includes barrier cream, 1 absorbent pad, no briefs/diapers, and regular offloading
What is Moisture associated Dermatitis
According to Steph, a stage 4 wound may reveal these " creatures of the deep"
What are bone, muscle, tendon or other deep structures
When assessing a heel on a patient with darker pigmented skin, this technique can help reveal a possible deep tissue injury by making discoloration easier to visualize
What is applying skin prep to create a sheen on the skin
After completing MAPPING for a newly identified pressure injury, the nurse should use this resource to guide wound treatment and prevention interventions
What are the Pressure Injury Guidelines
Neuropathy, poor glucose control, and improper fitting shoes are common risk factors for this wound
What is a Diabetic/neuropathic ulcer
This advanced wound therapy helps remove exudate and promotes granulation tissue formation and applies negative pressure to the wound bed
What is a wound vac