Stage That Wound
An area of non-blanchable erythema over a bony prominence
Stage I pressure ulcer
This dressing should never be placed directly on a skin tear
Tegaderm, Band-Aid, or tape (all acceptable answers)
A risk assessment completed on hospital admission, every shift, and with each change in condition
Braden scale
Who can stage a pressure ulcer?
The wound care RN
A partial or full thickness wound in which a flap may or may not be present
Skin tear
A shallow open area, over a bony prominence, involving the epidermis and dermis
Stage II pressure ulcer
Name two types of dressings that can be used on most wounds
What is Mepilex or Xeroform
How do you take a picture of a wound, and upload it to the chart?
Use CareAware phone camera App to take a picture.
The picture should include the wound, a wound ruler with measurements and patient information. Date, time, and initials should also be written on the ruler. The photo should be named describing the location of the wound.
How do you get ahold of wound care?
Tiger Text, place a wound consult for non urgent wounds, or call the wound care phone
Inflammation or erosion of the epidermis after exposure to moisture
Moisture associated dermatitis
An unopened, dry, boggy, purple, non-blanchable area over a bony prominence
Deep tissue injury
Can be changed every 5-7 days, gentle on the skin, handles moderate to large drainage, third-spaces drainage away from the skin and is the preferred dressing for Stage II pressure ulcers on the coccyx/sacrum
Foam dressing
What do you do/document if you find a suspected pressure ulcer? (Must name 5/6 steps)
Take a picture and upload it, document the wound with measurements in Cerner, notify the provider, place a wound consult, activate Pressure Injury IPOC, place Midas.
Name at least two treatment options for cutaneous candidiasis
Keep skin clean and dry, apply Nystatin or another antifungal, use InterDry or clean dry pillowcase to wick away moisture
A wound resulting from compromised blood flow to tissue that can take months to heal
Arterial ulcer
A pressure injury covered with sough or eschar
Unstageable pressure injury
Can be changed every 5-7 days, harsh on the skin, handles small to scant drainage, appropriate (but not the best choice) for Stage I and II pressure ulcers on the coccyx/sacrum
Hydrocolloid
What Braden score is the minimum threshold for pressure injury prevention interventions?
14
The rate of hospital-acquired pressure ulcers measured at a specific point in time
Prevalence
A dry wound typically located on the plantar foot or toes that is surrounded by hyperkeratotic tissue (callus)
Neuropathic (diabetic) foot ulcer
Describe the difference between a stage 3 and a stage 4 pressure ulcer
Stage 3 pressure injures extend into the fat but do not reach muscle, tendon, or bone like a stage 4 pressure injury
Discuss three ways to troubleshoot a wound vac that is alarming
Make sure that the wound vac is plugged in and on, reinforce the dressing to fix any potential leaks, ensure that the tubing is patient and draining, check to see if the canister is full and needs to be changed.
Name all three instances that you must document a 4-eyes assessment
On admission within 4 hours of arrival, transfer to another unit, and after prolonged surgery of 4 hours or more
Name five pressure injury prevention interventions
What are:
1.Q2 turns
2.Offloading heals and elbows
3.HOB <30 degrees (unless contraindicated)
4. Waffle Mattress overlay
5. Specialty bed
6. Wound consult
7. Single layer breathable pads
8. Lift or slide equipment to avoid shearing
9. Nutrition consult
10. Manage Moisture/incontinence (barrier cream)
11. Mepilex
A shallow wound, typically on the lower leg, which is irregular in shape and moist and usually painful
Venous insufficiency ulcer