What is my stage?
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.
What is stage 4 pressure ulcer/injury?
A pressure injury which is found within 24 hours of hospital admission
What is POA?
needed for patients who are out of bed to chair for prolonged periods
What is a waffle chair cushion?
physical assessment and communication of staging and orders between 2 nurses at shift change or transfer
What are 2 person skin checks?
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?
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
What is a stage 1 pressure ulcer/injury?
refers to a pressure injury where depth is obscured by slough or eschar. does not include "unable to view' or a non-pressure wound
What is an unstageable pressure injury?
One wedge at mid to upper back avoiding the coccyx
one on the lower body and legs
What is proper sacral offloading with the wedges?
How to ensure the waffle cushion is inflated properly
What is perform hand check q shift?
used on nasal cannula and high flow O2 for prevention of pressure injuries on ears
What are pillows/foam cushions?
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.
What is a stage 3 pressure ulcer/injury?
location to find interventions in the EHR
What is the Interventions column on Wound/Incision/Skin Flowsheet or the Pressure Ulcer Prevention Policy?
offloading heels either in the Tru Vue boots or with pillows
What is floating the heels?
fan folded covidien pads, towels placed between legs, more than 4 layers of linens, infrequent continence checks
What is increasing risk for skin breakdown?
Obesity, poor nutrition, moisture, prior skin ulcers, dehydration, sensory impairment, smoking, vasopressors, etc.?
What are several risk factors for developing pressure ulcers?
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.
What is a deep tissue pressure injury?
Discontinue/Reorder. then click Edit the order
What is how to correct pressure ulcer documentation?
this is used as a protective barrier for pts incontinent of urine or stool or both.
What is Sensicare zinc oxide moisture barrier? The clear barrier spray can be used for easier removal of the zinc oxide
bedside nurse notices the bed is plugged in and turned on and inflated!
What is a bed assessment?
Greatest risk factor for the pressure ulcer development.
What is immobility?
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.
What is a stage 2 pressure ulcer/injury?
pressure injury noted after 24 hours or on transfer to another unit
What is a HAPI?
Right lateral position first. Reducing speed of turn
Monitor response after 5-10 min. Provide micro-turns
Continuous lateral rotational therapy
What are considerations for the hemodynamically unstable?
mepilex foam on the sacrum, coccyx and heels
What is padding the bony prominences?
nasal cannulas, ET tubes, bipap, splints, c-collars, PEG tubes
What are devices which can cause pressure injury?