Staging
Mr. M is admitted to your unit with a UTI. During your two nurse admission skin assessment, you discover an area of partial thickness skin loss over his right heel. What stage is this?
STAGE 2
What tool is used to determine the risk of a pressure injury? Hint: it is required with every shift assessment
BRADEN SCALE
When is it appropriate to open a wound or pressure injury LDA vs documenting under head-to-toe skin integrity?
WHEN THERE IS A WOUND CARE OR PI DRESSING ORDER/TREATMENT IN PLACE
Your patient has a Braden Scale Score is less than 18. You identify that they are at risk for pressure injuries but do not currently have any skin breakdown. Which Plan of Care is most appropriate?
A. Pressure Injury – Prevention
B. Pressure Injury and/or Deep Tissue Injury
C. Skin Integrity – Impaired
A. Pressure Injury – Prevention
Mrs. R is admitted to your unit with r/o C. Diff and urinary incontinence. You are doing the admission head-to-toe skin assessment with another nurse on the team. Scattered areas of partial thickness skin loss across bilateral buttocks and perineum. The other nurse on your unit states, “That is a stage 2 pressure injury.” You know this is not a stage 2 pressure injury but rather ______.
MOISTURE-ASSOCIATED SKIN DAMAGE (MASD)
You are entering an LDA for a pressure injury. There is visible bone at the base of the wound. What stage is this?
STAGE 4
If the Braden Scale Score is less than 18, a purple banner will populate on the EPIC summary page indicating “****PATIENT AT HIGH RISK FOR SKIN BREAKDOWN****”. What order set should this prompt you to initiate?
You find a left buttock pressure injury during your admission assessment. The patient has been admitted for 20 hours. You open a pressure injury LDA, do you select “Present on Admission” yes or no?
YES
Your patient is followed by the wound care team for a stage 2 pressure injury to the sacrum/coccyx. Which Plan of Care is most appropriate?
A. Pressure Injury – Prevention
B. Pressure Injury and/or Deep Tissue Injury
C. Skin Integrity – Impaired
B. Pressure Injury and/or Deep Tissue Injury
EMS brought in Mrs. E after a fall. She is on Coumadin. She has scattered ecchymosis and has some open, weeping wounds on her arms and legs. Some have intact skin flaps, and some do not. What type of wound is this?
SKIN TEAR
Your patient was found down at home for an unknown amount of time. There is an intact area of non-blanchable purple discoloration over the left hip. What stage is this?
DEEP TISSUE INJURY (DTI)
You are working on the orthopedic unit. Your patient is POD 2 right hip arthroplasty. You check underneath the protective heel Mepilex foam dressings and find blanchable erythema. What more can you do to prevent breakdown?
How often are wounds or pressure injuries measured?
ON ADMISSION, TRANSFER, AND WEEKLY THEREAFTER
You find a stage 2 pressure injury on your head-to-toe assessment. You open an LDA and document a thorough wound assessment. What is the next step in treatment?
INITIATE STAGE 1/2/DTI PRESSURE INJURY ORDER SET AND PLAN OF CARE
Your patient is on hemodialysis MWF. They complain of pruritus (itchiness) before treatments. You note linear scratches on your patient’s arms and legs. What do we call these types of wounds?
EXCORIATION
Mrs. B is admitted with an infected sacral wound. There is a foul odor coming from the wound and it is covered with eschar and slough. You are unable to visualize the wound base. What stage is this?
UNSTAGEABLE
You receive a post-op patient from the ICU. You are notified in report that the patient’s Braden Score is less than 18. You put turning wedges, protective foam dressings, and heel elevation devices in the room for his arrival. His moisture sub-scale score on the Braden Scale is less than 3, what additional pressure injury prevention tool can you order?
ALAL (AIR) MATTRESS
Your patient was found down for an unknown amount of time. There are areas of non-blanchable purple discoloration to the left hip and the left buttock, these are NOT bruises. You should open two DTI (deep tissue injury) LDAs. True or False?
TRUE
After placing the order for order sets, you must notify the hospitalist. True or False?
TRUE
Mr. T is incontinent of large amounts of liquid stool. Bilateral buttocks are reddened, bleeding, and painful. There are scattered areas of partial thickness skin loss. How do we describe this skin condition?
DENUDED
Your patient is a paraplegic and wheelchair-bound at baseline. You notice a full-thickness ulcer over the right ischial tuberosity during your head-to-toe assessment. The wound bed is red and moist with scattered areas of yellow adipose tissue. There is NO muscle, bone, or tendon.
You are working in the cardiac med unit. Your patient comes in with acute heart failure and the provider orders a Lasix drip. The patient is unable to use the urinal or get to the commode independently and is having incontinent episodes. What would you use to protect his skin against incontinence?
BARRIER CREAMS
When is the admission skin check with a second RN required?
ON ADMISSION AND TRANSFER TO ANOTHER LEVEL OF CARE
What order mode can you order the pressure injury and skin tear order sets under?
NOTIFY-INITIATE HOSPITAL POLICY/PROTOCOL-COSIGN TO BE SENT
Mr. C has a highly exudative venous ulcer. He came in with garbage bags around his legs to collect the drainage. The peri-wound skin is white and pruned in appearance. How would you describe the peri-wound skin?
MACERATED