Risk Factors
Name three risk factors for developing pressure injuries.
What is obesity, poor nutrition, prior skin ulcers, dehydration, sensory impairment, smoking, immobility
This is how often the Braden Scale should be documented on the nursing flow sheet.
What is once a shift
Used on patients with at risk/pressure areas on coccyx when patient in chair
What is air cushion or waffle
Use of this with a sacral foam border dressing (mepilex) is contraindicated
What is calmoseptine or zinc
The greatest risk factor for the pressure injury development.
What is Immobility
This type of check & documentation is done on admission and transfer
What is the two-person skin check
Partial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also be present as an intact or ruptured serum-filled blister.
What is Stage 2
When patients are incontinent of stool this is used as a skin protective barrier
What is calmoseptine or zinc
Patients at nutritional risk should be offered this.
What is high protein or nutritional supplements
Immobility for what time frame can cause tissue ischemia?
What is 20 minutes
Where pressure injury resources are found online at CMH
What is the CMH Portal, under clinical resources and SWAT Team (Skin Wound Assessment Team)
Full thickness skin & tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
What is Stage 4
Isoflex, Isolibrium, and Air Mattress
What are pressure relieving/reducing surfaces
Frequent repositioning can prevent injury on which three high risk pressure points? (more than 3 possible)
What is heel, sacrum/coccyx, hips, knee, occipital, buttocks
Parallel frictional force that occurs as patients are dragged during repositioning as opposed to being lifted and moved.
What is shearing
These are the people the nurse notifies/consults when a patient has a pressure injury.
Patient, Family, Provider, Charge Nurse, Dietary, and Wound Nurse
Full thickness skin loss, in which adipose (fat) is visible in the ulcer & granulation tissue & epibole (rolled wound edge) are often present. Slough &/or eschar may be visible.
What is Stage 3
What blood work might be assessed to determine nutritional status?
What is pre albumin or albumin level
Water filled gloves, sheep skin, and donut rings
What worsens ischemia if used and routine use should be avoided (may be used in procedural situation)
This scale is utilized to assess patient's risk factor for pressure injury by assessing patient's: sensory perception, moisture, activity, mobility, nutrition, friction, and shear
What is the Braden Scale
This replaces our nursing pressure ulcer order set
What is a Pressure Injury Power Plan
Full thickness skin & tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
What is Unstageable
Pressure injury from oxygen sat probes, NG tubes, braces, drains, catheters, Bipap/CPAP, face masks, IV tubing, compression sleeves or stockings, endotracheal tubes
What is an MDRI: Medical Device Related Injury
What device should be used on patients with 2 or more of these criteria: Braden<14, BMI>35, current sacral press. inj, high risk pt (vent, pressors, Hx PI, 3rd spacing)
What is Turn & Position System or Tortoise