Risk Factors
What are some factors that affect skin integreity
What is,
State of health and lifestyle, diagnostic and therapeutic measures, and illness, consistent moisture, altered mental status, immobility
Ongoing skin assessment, good hygiene, humidity for dry skin, and skin protectants are good for pressure injuries
True or False
What is...
TRUE
This stage shows full thickness, skin loss, with exposed bone, tendon, and muscle
What is...
Stage 4
The stage where the skin is intact, but red, and doesnt blanch
What is... Stage 1
Parallel frictional force that occurs as patients are dragged during reposionting as opposed to being lifted and moved.
What is....
Shearing
As we age our skin...
what is.....
Gets thinner due to loss of adipose tissue
The most important factor to prevent pressure ulcers in immobile patients.
What is...
Repositioning every 2 hours
Full thickness skin loss, subcutaneous fat tissue is exposed.
What is ....
stage 3
The three stages of Wound healing
What is..
Primary
Secondary
Tertiary
Who are people the nurse notifies when a patient has a pressure ulcer?
What is...
Patient, Family, Physician, and Dietary
What parts of the body are most prone to pressure injuries
What is...
Boney prominences,
Example, Elbows, sacrum, heels
This type of surface can help distribute pressure and prevent skin breakdown.
What is...
pressure-relieving mattress or cushion
You see a sacral wound covered completely by black eschar, why cant you assign a stage?
Because the depth of tissue is not visable, the ulcer is unstagable
This is a type of wound care that is not used with patients who are bleeding, and sucks out dead tissue
What is...
Negative pressure therapy
Or Wound Vac
This is how often the Braden Scale should be documented on the nursing flow sheet.
What is...
Daily
A patient in the ICU who is sedated and on a ventilator is at higher risk for pressure ulcers due to this major factor
What is...
Immobility
This tool is used by nurses to assess a patient's risk of developing a pressure ulcer by scoring factors.
What is...
The Braden scale
This is a purple or maroon localized are of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure/ sheer.
What is...
Deep tissue Injury
Which of the following phases are not included in wound healing
Hemostasis, induction phase, inflammatory response, or remodeling
What is...
Induction phase
This mineral and/or vitamins, essential for immune function and tissue repair, may be supplemental to accelerate healing
What is...
Zinc, Vitamin A and D
This behavioral health condition may contribute to pressure ulcer risk due to poor self-care, immobility, and nutritional neglect.
What is...
Depression (or mental illness)
This nutritional intervention helps support skin integrity and wound healing.
What is...
Providing adequate protein, calories, and fluids?
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
What is the name of the commonly used dressing that can help remove excess fluid from a wound bed and promote healing by maintaining a moist environment?
What is...
Hydrocolloid dressing
Immobility for what time frame can cause tissue ischemia?
What is....
20 minutes