Risk Factors
Obesity, poor nutrition, dehydration, sensory impairment, smoking, and immobility
What are risk factors for pressure injuries?
This is how often the Braden Scale should be documented on the nursing flow sheet.
What is daily
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
What is suspected Deep Tissue Injury
Used on patients with pressure areas on the coccyx for example
What is an air cushion
Aloe vesta is an example
What is a skin protective barrier
Greatest risk factor for pressure injury development.
What is Immobility
Can photos be used to track a pressure injury in a patient?
Yes
Partial thickness skin loss involving epidermis and/or dermis. The injury is superficial, presenting as an abrasion, blister, or shallow crater
What is Stage 2
Calmoseptine is an example
A skin protective barrier for patients incontinent of stool
Patients with or at nutritional risk for pressure injury should be offered this supplement, usually in the form of a drink.
What is a high-protein supplement
Immobility for just this long can cause tissue ischemia.
What is 20 minutes
Once a pressure injury is identified, this is taken on initial assessment, every 7 days, and on discharge.
What is a photo of the injury
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage involving muscle.
What is Stage 4
An air mattress is an example of this device
What is a pressure-relieving device
Heels, sacrum, hips, knees, occiput, and buttocks
What are pressure points at risk of injury
The parallel frictional force that occurs as patients are dragged during repositioning as opposed to being lifted and moved.
What is shearing
Patient, Family, Physician, Dietary, and Wound Care Nurse
Who are the people the nurse notifies when a patient has a pressure ulcer or who are members of the collaborative interdisciplinary team.
Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
What is Stage 3
What blood work should be assessed to determine nutritional status?
What is the pre-albumin level
Who has 24/7 responsibility for assessing for pressure injuries in patients?
Who is the nurse.
This scale is utilized to assess patient's risk factors for pressure injuries by assessing sensory perception, moisture, activity, mobility, nutrition, friction, and shear
What is the Braden Scale
When should the finding be documented in the electronic health record?
Immediately upon noticing the pressure injury
Full-thickness tissue loss where the base of the ulcer is covered with slough and or eschar in the wound bed.
What is Unstageable
This assessment is done on every admission to identify risk reduction strategies to be utilized for the patient.
What is the Prevention Level
The specially trained nurse who is a resource for pressure injury prevention and care
What is a wound care nurse and/or ostomy nurse