Wound Stages
Risk Factors
Braden Scale
Fun Facts
Client Teaching
100
Intact skin, Pink/reddened area does not go away when pressure removed, non-blanchable
What is a stage 1 pressure injury?
100
Reduction in the amount and control of movement a person has
What is immobility?
100
The Braden Scale assesses based on this many risk factors.
What is 6?
100
Skin is made up of these two main layers
What are the epidermis and dermis?
100
The maximum amount of time between repositioning a patient
What is 2 hours?
200
Open skin, wound bed has fatty tissue
What is a stage 3 pressure injury?
200
Force of 2 surfaces moving across each other
What is friction?
200
Ability to respond meaningfully to pressure related discomfort
What is sensory perception?
200
Fuel for cell energy to promote wound healing
What are calories?
200
The frequency which nurses/caregivers should check skin
What is daily?
300
Intact skin, purple or maroon color
What is a deep tissue pressure injury?
300
Causes weight loss, muscle atrophy and the loss of subcutaneous tissue
What is inadequate nutrition?
300
Ability to change and control body position
What is mobility?
300
The amount, color, consistency and odor of wound drainage
What is exudate?
300
A meal substitute for a patient who is not meeting their nutritional needs
What are high protein oral nutrition supplements?
400
What is an unstageable pressure injury?
400
Combination of friction and pressure
What is shear?
400
Ability to walk, bear own weight, a spend time out of the bed
What is degree of physical activity?
400
Assessing this requires extra care and consideration as hyperemia is not present and the skin is non-blanching
What is darkly pigmented skin?
400
The recommended height of the head-of-bed for reducing friction and shear
What is below 30 degrees?
500
Open skin, pink granulated tissue
What is a stage 2 pressure injury?
500
Reduced level of awareness, less able to recognize and respond to pain with prolonged pressure
What is decreased mental status?
500
A score of 11 on the Braden Scale
What is high risk?
500
The red, moist tissue composed of new blood vessels
What is granulation tissue?
500
Using pillows and position assists, adding support surfaces, creating a reposition and walking schedule
What are ways to redistribute pressure?