Staging
An area of non-blanchable erythema over a bony prominence
Stage I pressure ulcer
A pressure injury risk assessment completed on hospital admission, every shift, and with each change in condition
Braden Scale
Surgical incision erythema or draining, fistula, wound vac, ostomies. wound associated with Peg/Trach
Appropriate wound consult
Wound cleanser. Can be used for wet to dry dressings. Biocompatible, safe, effective, natural. Mimics the normal pH of human skin. Cleanses, debrides and removes microorganism from the wound and reduces wound odor. Required MD order.
VASHE
Used prophylactically and as a secondary dressing. Provides protection and cushion to bony prominences. Protects against shearing in our low Braden risk score patients. Do not apply cream/ointment with foam dressing it can trap excessive moisture and places the patient at risk for moisture-related skin damage
Foam Dressings
A shallow open area, over a bony prominence, involving the epidermis and dermis
Stage II pressure ulcer
Who can stage a pressure injury
Wound Care Nurse
Surgical incision intact, suture or staple removal, uncomfortable bed, Peg/trach with no wound, Prevena wound vac.
Inappropriate wound consult
Helps relieve and treat itching, burning, cracking, scaling, redness, and discomfort associated with most common superficial fungal infections. MD order required.
Phytoplex antifungal ointment
Soft, absorbent material that transforms into a gel on contact with wound fluid. Contours to wound bed. Protects peri wound from maceration. Antimicrobial dressing. Silver Ions are released as drainage is absorbed. Cut to size of the wound
Aquacel Ag
An unopened, dry, boggy, purple, non-blanchable area over a bony prominence
Deep tissue injury
Name all 3 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
Tools for repositioning q2hrs
Comfort glide and wedges
Thick zinc paste is a moisture barrier that forms a layer of protection between skin and urine/stool/sweat. Does not need an MD order.
Calazime lotion
Non-adhesive wound dressing with built-in cleanser. Fills and conforms to wound base, absorbs drainage, maintains moist would environment for healing. Available in supply rooms.
Polymem
A pressure injury covered with sough or eschar
Unstageable pressure injury
Consists of 6 subscales = sensory perception, moisture, activity, friction and shear and nutrition
Braden Scale Tool 6 Subscales
Overlay aids with pressure reduction over body promises. Available in medication room. No order is needed.
Mattress Overlay
Clear moisture barrier ointment that helps PREVENT and TREAT most topical skin irritation due to moisture related skin damage. Part of the basic skin care regimen. Clean, moisture, protect. Does not need an MD order.
Critic Aid Clear Barrier Cream
Absorbs up to 150ml/hr wound exudate. Locks fluids away from wound and selectively debrides slough issues from wound base. Available in supply rooms on unit.
Drawtex
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
Measuring a wound: Length (top to bottom), Width (side to side), depth (deepest part of the wound) and assess for any tunneling or undermining.
For tunneling and undermining: always start at 12 o’clock (pointing towards the patient’s head) 6 o’clock ((pointing towards the patient’s feet and move around the clock 1,2,3,4,5,etc.
Proper Wound Measuring
Only use on Incontient patients when out of bed. Should NOT be used on patients in bed. Trap moisture and cause skin breakdown
Diapers
Moisture barrier cream that inhibits fungal growth and treats candidiasis, jock itch, ringworm, and athlete’s foot. Provides a moisture barrier against urine and feces. Does not need an MD order.
BAZA Cream
Debrides wounds with slough tissue faster than autolytic debridement. Does not have antimicrobial properties, which is why we often use in conjunction with Vashe. Needs MD order.
Santyl