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?
What is Stage 2
What tool is used to determine the risk of a pressure injury? Hint: it is required with every shift assessment
What is 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
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 ______.
What is 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?
What is 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?
What is Pressure Injury Prevention Order Set
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?
What is Yes
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?
What is 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?
What is 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?
What is Heel Elevation (BOOTS, PILLOWS, ETC)
How often are photos of pressure injuries/wounds updated?
What is on Admission and Weekly (Wound Wednesday)
What should mepilex dressings be labeled with when placing on the patient?
What is Time, Date, Initials, "P" for Prevention, "T" for Treatment
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?
What is Unstageable
You receive an intubated and sedated post-op patient in the ICU. You are notified in report that the patient’s Braden Score is less than 18. The patient is unable to turn independently, unable to lift heels, and has blanchable erythema to the sacrum. What pressure injury prevention products do you anticipate using? (Hint: there are 3 answers)
What is turning wedge, heel elevation devices, sacral mepilex
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?
What is True
Your patient is unable to lift his heels independently. He has offloading boots in place. Does he need heel mepilex dressings?
What is No
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.
What is Stage 3
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?
What is External Urinary Catheter
When is the admission skin check with a second RN required?
What is on Admission and Transfer in Level of Care
What is the maximum suction setting recommended for external urinary catheters?
What is 100 mmHg