Pressure Injury Staging
Muscle and bone exposed in a clean wound bed
What is a Stage 4 Pressure Injury?
Turning and repositioning schedule for high risk patients
What is every 2 hours?
Bed recommended for Braden score 14 or less
What is a low air loss surface?
Placed with a Foley catheter to prevent movement and medical-device related pressure
What is stat lock?
Consult to place when HAPI is discovered
What is wound consult or dietary consult?
Intact skin with non-blanchable red skin discoloration
What is Stage 1 Pressure Injury?
Settings to adjust on First Step low air loss mattress
What are height and weight?
What score does VPH consider high risk for skin breakdown?
What is 14 and below?
Placed under the trach plate to prevent pressure
What is foam pad?
Done in RL Solutions after discovery of HAPI
What is incident report?
Purple non-blanchable skin discoloration over a bony prominence
What is Intact Deep Tissue Pressure Injury?
A device used to reposition a patient at a 30 degree angle
What are wedges?
Friction and shear category score for a contracted patient requiring maximum assistance with repositioning
What is 1?
Can cause pressure injury on the ears and face
What is nasal cannula, hi flo, or facemask?
Most common place for a HAPI
What is the sacrococcyx?
Intact or non-intact fluid-filled blister over a bony prominence
What is a Stage 2 Pressure Injury?
2 ways to offload the heels
What are pillows, Heelmedix, and Heelzup Cloud?
Moisture category score for a patient who is constantly moist by perspiration, urine, or stool
What is 1?
Frequency of skin assessment under medical devices
What is at least every shift?
Two people informed of change in skin condition
Who are the physician and the patient/family?
Wound that is 80% covered with yellow slough and black eschar with foul-smelling drainage with no palpable muscle, bone, ligament, or tendon
What is an Unstageable Pressure Injury?
Name 3 medical devices that prevent pressure
What are wedges, Heelzup cloud, EHOB/waffle cushion, gel donut cushion, low air loss surface, Heelmedix?
Name 2 categories on the Braden Scale
What are sensory perception, moisture, activity, mobility, nutrition, friction and shear?
To prevent skin breakdown around rectal tube
What is apply Calazime every shift?
Two things to be included on the photo description of the HAPI
What are location, measurement, staging, 2 RN signatures?