Name three risk factors for developing pressure ulcers.
What is obesity, poor nutrition, prior skin ulcers, dehydration, sensory impairment, smoking, immobility, moisture
100
This is how often the Braden Scale should be documented in Power Chart.
What is daily
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 a 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 an air cushion
100
When patient's are incontinent of urine this is used as a protective barrier.
What is Z-Guard
200
Greatest risk factor for pressure injury development.
What is Immobility
200
This will be placed in the progress notes and the front of the chart by the person taking the photo.
What is Yellow Photo taken sticker
200
Partial thickness skin loss involving epidermis and/or dermis, the ulcer is superficial presenting as a blister, or shallow crater
What is a Stage 2
200
When patient's are incontinent of stool this is used as a skin protective barrier
What is Z-Guard
200
Patient's at nutritional risk should be offered this.
What is high protein supplement
300
Imobility for what time frame can cause tissue ischemia?
What is 20 minutes
300
Once pressure ulcer identified, this is taken on initial assessment, every 7 days and on discharge.
What is a photo
300
Full thickness skin loss with extensive destructin, tissure necrosis, or damage involving muscle and/or bone
What is a Stage 4
300
Heel Raiser Pro, Sofcare wheelchair cushion
What are pressure relieving devices
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, Dietary, and Wound Nurse
Who are people the nurse notifies when a patient has a pressure injury
400
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
What is a Stage 3
400
What blood work should be assessed to determine nutritional status?
What is the pre albumin level
400
Donut rings or invalid cushions
What increases further ischemia if used and should not be used.
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
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 an IPOC
500
What device is used for patients and checked daily for proper use?