Risk Factors
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
Use for sitting or while in bed. Good for ICU patients on Vasopressor
What is a waffle cushion
Use for “at risk” skin barrier protection, treatment for partial thickness skin injury, and as barrier for peri-stomal tube drainage
What is Zinc Oxide Paste Skin Protectant
Greatest risk factor for the pressure ulcer development.
What is Immobility
Place consult to the Wound, Ostomy, and Continence Nurse (WOCN) service for patients at risk for pressure injury development with a BS of ≤ 16
What is ≤ 16
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
Unit based Clinical Research Nurses who have a strong interest in wound, ostomy, and continence nursing and serve as resources and liaisons to their fellow staff.
Who is the Skin Wound Action Team (SWAT)
Patient's at nutritional risk should be offered this.
What is high protein supplement
When should nurses document skin assessment findings after thorough visual head-to-toe skin assessment
What is upon admission, daily, change in clinical status, or transfer,
Full thickness skin loss with extensive destruction, tissue necrosis, or damage involving muscle.
What is Stage 4
Make sure to apply within the Sacrum gluteal fold. Do Not tent over Or Type “Mepilex” fold, must maintain contact with skin or will create moisture.
What is a Sacral Mepilex border
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
What blood work should be assessed to determine nutritional status?
What is pre albumin level
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
Full thickness tissue loss where the base of the ulcer is covered with slough and or eschar in the wound bed.
What is Unstageable
Flatten before turning. Turn Or Type “Positioner” patient and place under patient then squish it toward the body to keep pt in place
What is a Z-flo positioner