Show:
Risk Factors
Documentation
What's my Stage
Prevention
Prevention 2
100
Name three risk factors for developing pressure ulcers.
What is obesity, poor nutrition, prior skin ulcers, dehydration sensory impairment, smoking
100

This is how often the Braden Scale should be documented on the nursing flow sheet.

What is daily or any significant changes?

100
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
100

Used on patient's with pressure area's on coccyx or risk for injury when getting out of bed to chair

What is air cushion?

I will also take a Waffle cushion or Mepilex dressing

100

When patient's are incontinent of urine this is used for skin protection.

What is barrier spray or barrier cream

200
Greatest risk factor for the pressure ulcer development.
What is Immobility
200

Patient develops a pressure injury after being admitted

What is a hospital acquired pressure injury

200
Partial thickness skin loss involving epidermis and/or dermis, the ulcer is superficial presenting as a abrasion, blister, or shallow crater
What is Stage 2
200

When patient's are incontinent of stool this is used as a skin protective barrier

What is triad, barrier cream

200

Patient's at nutritional risk should be offered this.

What is high protein supplement: Ensure or Boost

300

Immobility for what time frame can cause tissue ischemia?

What is 20 minutes

300

Once pressure ulcer identified, the next steps of initial assessment.

What is documented on flowsheet and wound consult ordered. 

300
Full thickness skin loss with extensive destructin, tissure necrosis, or damage involving muscle.
What is Stage 4
300

Tempur Med, alternating Mattress, and low Air Mattress

What are pressure relieving mattresses to relieve or prevent pressure ulcers

300

By frequently repositioning patient you can decrease the occurrence of pressure ulcer on which three high risk pressure points?

What is heel, sacrum, hips, knee, occipital, buttocks

400
Parallel frictional force that occurs as patients are dragged during repositioning as opposed to being lifted and moved.
What is shearing
400

Patient, Family, Physician, and Wound Nurse

Who are people the nurse notifies when a patient has a pressure ulcer

400
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not throught, underlying fascia.
What is Stage 3
400
What blood work should be assessed to determine nutritional status?
What pre albumin level
400

Oxygen tubing, feeding tubes and casts

What are medical devices that can increase pressure injury

500
This scale is utilized to assess patient's risk factor for pressure ulcers by assessing patient's: sensory perception, moisture, activity, mobility, nutrition, friction, and shear
What is the Braden Scale
500

One of Professor Carroll sayings:

"If it is not documented, It is not _____!"

Done

500
Full thickness tissue loss where the base of the ulcer is covered with slough and or eschar in the wound bed.
What is Unstageable
500

This patient assessed level is done on every admission to identify risk reduction strategies to be utilized for the patient.

What is a Prevention Level

500

What device should be used on patients and checked daily for proper use?

What is pressure reduction mattress or bed