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SKIN ASSESSMENT
PRESSURE ULCER PRECAUTIONS
SKIN TEARS
BRADEN SCALE
WAFFLE MATTRESS VS LOW AIR LOSS MATTRESS
100
Skin temperature, dryness, bruising, observing for any breaks in skin integrity.
What is assessed in a daily skin assessment?
100
Non blanching erythema.
What is a stage 1 pressure ulcer?
100
Removal of epidermal skin layer.
What is a skin tear?
100
Every shift and within 4 hours of admission.
When is a Braden scale done?
100
Lasts about one month and goes home with patient.
What is a waffle overlay?
200
Buttocks, under pannus, under breasts.
Where are common areas for moisture and yeast.
200
Elderly, infirm, those with mobility issues.
Who is at risk for a pressure ulcer?
200
Daily
How often should dressings be changed for a skin tear?
200
Banner Health employee website: tools, skin resources, Braden Scale
Where do I find information on the Braden scale/
200
WOCN and Physician.
Who can approve a waffle overlay or low air loss mattress?
300
Red areas with satellite lesions.
What does yeast infection look like on the skin?
300
Banner Health employee website: tools, skin resources, pressure ulcer prevention
Where do I find information on pressure ulcer prevention?
300
Staff RN, WOCN, Physician
Who can enter skin tear protocol orders
300
To accurately predict who will develop pressure ulcers.
Why do we do Braden scales?
300
Banner health employee website: tools, skin resources, waffle overlay vs low air loss mattress.
How do I get information on waffle overlay vs low air loss.
400
Banner Health Employee Website: tools, skin resources, skin assessment
Where do I find skin assessment information
400
Heels and coccyx.
Where are the most common sites for pressure ulcers?
400
Banner Health employee website: tools, skin resources, skin tear protocol.
Where do I find skin tear protocol orders?
400
6-23.
What is the range on a Braden scale?
400
Patient has bowel or bladder incontinence, stage 3 or 4 ulcers on the trunk.
When is a low air loss mattress needed?
500
Pressure wounds behind the ears.
What can oxygen tubing cause?
500
Turning every 2 hours, floating heels, every shift skin assessment, keeping skin clean and dry.
What are pressure ulcer precautions?
500
Wound gel, adaptic, gauze, soft rolled kling daily.
What is skin tear protocol?
500
The categories of the Braden scale.
What is sensory perception, moisture, activity, mobility, nutrition, friction and shear?
500
Place your hand under the mattress and see if patient is bottoming out.
What should be done to check a EHOB overlay for proper inflation?