Braden Scoring
Patients with Braden scores at or below this number are considered at risk for skin breakdown.
What is 18?
Your patient has an area of discoloration at the sacrum. Upon assessment, the skin is intact and fails to blanch. You apply _____ & document _______.
What is Apply Foam dressing and document stage 1 pressure ulcer?
This thick ointment creates a moist wound environment and helps kill bacteria.
What is Medihoney?
The following documentation is mandatory within 24 hours of an admission arrival and within 8 hours of a transfer arrival.
What is the 2-person skin assessment?
This is the process for ordering a specialty bed for patients whose Braden scores indicate moderate, high, or severe risk.
What is enter "specialty bed" order in EPIC, indicating Centrella Max bed in the comments, and call guest services?
Patients may qualify as "bedfast" only if they have one of these TWO activity orders.
What are "strict bedrest" and "logroll precautions?"
Note: "Bedrest" is a default admission order that should be questioned after tests/procedures. "Strict bedrest" is a mandated order, for example, following a skin/muscle graft.
These two things can help when assessing wounds on darker pigmented skin.
What are (any two of the following) use bright light, compare area to other non-affected skin, palpate, ask the patient, take pictures?
Refer to image. Following his arrival to the unit, you remove a brief from your 83 year old patient and see this. Identify appropriate treatment AND documentation.
What are (treatment options) leave open to air, zinc spray, clear moisture barrier ointment and
(acceptable documentation options) two-person skin assessment, upload image to chart?
The Braden Score is documented at this frequency, and PRN with any changes.
What is Qshift?
Q2 turns/repositioning is the expectation for all patients with these Braden scores.
What are scores less than or equal to 18?
Your oriented trauma patient has BLE fractures, is continent, adjusts himself in the bed, and transfers to the chair with assistance. He eats about half his meals. This is his Braden score.
What is 17? (Mild Risk)
Refer to image. Name the classification or stage of the pressure injury.
What is unstageable?
Refer to image. You remove a dry dressing on a direct admit patient, to find this wound. You manage the wound with moistened gauze and consult wound care. You know that it is mandatory that you document these TWO things.
What are a Care Event and a Two-Person Skin Assessment?
This must be performed and documented if a patient is up in a chair for more than 2 hours.
What is repositioning (or off-loading pressure)?
Name 3 devices you can use to offload a patients heels.
What are HEELZ up mat, pillows, and Z-Flex boot?
The Braden Scale has 6 subscales, including Moisture and Activity. These are the remaining four.
What are Sensory perception, Mobility, Nutrition, Friction & shear?
These are FIVE common examples of medical devices that can cause device-related pressure injuries.
What are (any 5 of the following) Trachs, Cervical collars, NGT/DHT, oxygen tubing, peg tubes, drains/tubes/Flexiseal, splints/braces, SCDs, footboard?
Refer to image. After weeks in the hospital, your transfer patient arrives with this CPAP-mask-related wound. You proceed with these THREE steps.
What is photograph image, perform 2-person skin assessment, ensure wound care has been consulted?
This is the expectation when you find a new pressure injury.
What is (1) Document wound on LDA, (2) fill out a care event, and (3) consult wound care IF pressure injury is greater than stage 2 or unstageable?
Other than offloading and foam dressings, you can do this to prevent pressure injuries.
What is mobilize your patients?
Your patient has a history of stroke, right-sided weakness, wheelchair-bound at baseline, and expressive aphasia. She is currently NPO, following suspected aspiration. She was admitted from her SNF with a sacral Stage 1 pressure injury and is unable to reposition independently in bed. A Purewick is in place for urinary incontinence. This is her Braden Score.
What is 11? (High Risk)
On assessment, you discover a soft boggy spot. You suspect that this wound is a __________ and requires a _________ consult.
What are deep tissue injury and wound care consult?
Refer to image. You change the dressing daily or BID, as ordered by wound care. You expect the dressing change to require the following FOUR steps.
What is (1) remove old packing (2) cut & moisten new packing (3) pack wound in "fluff, don't stuff" manner, (4) label with time/date/initials?
This is where you document preventative skin interventions.
What is "skin care detail" under Hygiene, in flowsheets?
Name 5 common bony prominences, other than coccyx/sacrum, that require offloading when repositioning a patient.
What are (any 5 of the following) occiput, scapula, elbow, hips, shoulder, outer knees, ankles?