Stage This
Non-blanchable erythema of intact skin
What is a stage 1 pressure injury
This product has a deep, v-cut heel well that fully offloads the heel while the patient is in bed.
What is a Tru-Vue boot
Patients with ________ will benefit from prevention strategies such as: lifting device for turning, repositioning and transfers, reducing friction and shear to skin areas at risk.
What is increased friction and shear
Area on lateral malleolus has wound bed of 85% black, 10% yellow and 5% red.
What is an unstageable pressure injury
Only the wound care nurse can stage a pressure injury
Fiction. the unit RN should complete the initial pressure injury staging using the NPIAP definitions. Stage 1 & 2 wounds may be crosse checked by a wound resource nurse or unit skin champion. Stage 3 and 4 pressure injuries, DTI and unstageable wounds should be assessed by a certified wound nurse.
Persistent non-blanchable deep red, maroon or purple discoloration of intact or non-intact skin
What is a deep tissue pressure injury
A clear prevention dressing used on intact skin
What is Optiview Clear
Patients with ___________ will benefit from prevention strategies such as: Nutritional status assessment, nutritional support, encourage fluid intake, offer nutritional snacks
What is decreased nutritional intake
Area over sacral coccyx is red and purple in areas and has a blister over purple boggy tissue
What is a Deep Tissue Pressure Injury
Providers (Physicians and APRNs) are responsible for putting in the wound care orders
Fiction. RNs have the autonomy to assess and create the wound care treatment plan, unless there is an overriding physician treatment order.
Full-thickness skin and tissue loss with slough or eschar
What is an unstageable pressure injury
This paste creates a moist wound environment that facilitates healing and autolytic debridement. It is ideal for wet or irregular surfaces.
What is Triad Hydrophilic Wound Dressing
Patients with ___________ will benefit from prevention strategies such as: keep skin clean and dry, use mild cleansing agent for hygiene, perineal care and topical moisture barrier every shift and PRN
What is increased moisture
Small area on lateral phalanx of left foot is pink, red and moist with exposed dermis. It appears it may be a ruptured blister.
What is a stage 2 pressure injury
You should consult the Wound Care Nurse for all pressure injuries.
Fiction. The wound care nurse should be consulted for: Stage 3 &4 PIs, DTIs or Unstageables, a new HAPI or wounds that are not healing or have worsened. The wound care nurse does not need to be consulted for Stage 1 or 2 pressure injuries unless there is a concern.
Partial-thickness skin loss with exposed dermis with no visible adipose or deep tissues
What is a stage 2 pressure injury
This cushion has multiple adjustable valves to allow for a customized air distribution.
What is a Roho wheelchair cushion
Patients with ________ will benefit from prevention strategies such as: Ambulation per MD order, positioning, provide pressure redistribution, range of motion exercises
What is decreased physical activity / decreased mobility
Area on coccyx has full-thickness loss with tunneling and rolled edges. Wound varies in depth and is yellow, red and pink. In the center of the wound is a white spot that is hard upon palpation.
What is a stage 4 pressure injury
The stage of pressure injury must be documented at minimum on admission and discharge.
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone
This dressing has a built-in wound cleanser, decreases pain and inflammation and has been shown to accelerate the healing of DTPIs
What is PolyMem
Patients with ________ will benefit from prevention strategies such as: assess footwear to insure proper fit, assess splints/orthotics to ensure fit, alignment and skin integrity, avoid positioning on bony prominences
What is decreased sensation
Area over heel has exposed fat with granulation tissue. Wound bed is red, yellow and pink with epibole (rolled wound edges).
What is a stage 3 pressure injury
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