Name three risk factors for developing pressure injuries.
What is obesity, poor nutrition, prior skin ulcers, dehydration, sensory impairment, smoking, moisture exposure, decreased mobility,
100
This is how often the Braden Scale should be documented on the nursing flow sheet.
What is each shift
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 Deep Tissue Injury
100
Used in the chair on patient's with pressure areas on coccyx or risk for injury
What is a static air cushion
100
When patient's are incontinent of urine this is used as a protetive barrier.
What is Criticaid
200
Greatest risk factor for the pressure injury development.
What is Immobility
200
This is how often the wound measurements are taken and placed in the chart by the bedside RN
What is on admission and weekly on Wound Wednesday
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 pressure injury
200
When patients are incontinent of stool this is used as a skin protective barrier
What is a zinc barrier - desitin
200
Patient's at nutritional risk should be offered this.
What is high protein supplement
300
This is how long a patient should stay up in the chair
What is no more than 2 hours at a time
300
Once a pressure injury is identified, the bedside RN should
What is add a parameter in the computer, complete an incident report, and place a consult for the Wound Nurse
300
Full thickness skin loss with extensive destructin, tissure necrosis, or damage involving muscle.
What is Stage 4 pressure injury
300
This is used for repositioning patients that are difficult to keep turned
What is a z-flo positioner
300
By frequently repositioning patient you can decrease the occurrence of pressure ulcer on which high risk pressure points?
What is occiput, coccyx/sacrum, and heels
400
Parallel frictional force that occurs as patients are dragged during repositioning as opposed to being lifted and moved.
What is shearing
400
This is where WOCN places wound recommendations for the bedside RN
What is Wound Care Per Nursing under patient orders
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 pressure injury
400
This specialty bed can be ordered for a patient with pressure ulcer injury
What is the dolphin bed
400
Patient with these devices are at risk for pressure ulcers
What is a trach, DHT, NG tube, ET tube, O2 tubing
500
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
500
This is where the WOCN places photos, wound, measurements, description, and recommendations
What is the Wound Care Note in the Documents section
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 pressure injury
500
This can be placed on a bed for a patient with frequent loose stool to reduce moisture from skin surface
What is a microclimate overlay or topper available from UHS
500
In order for the critical care bed to provide the optimal pressure redistribution this must be entered daily and whenever the bed has been unplugged