Pressure Injuries (PI)
Damage to the skin and/or underlying tissue usually over a bony prominence or related to a medical or other device
What is a pressure injury?
Pressure injury risk assessment documentation
What is Braden Scale?
How to differentiate between tunneling and undermining
Tunneling occurs when a narrow passage forms within the wound bed. Undermining is erosion beneath the wound edges around the perimeter of the wound
Team member to call for assessment and treatment recommendations of PI Stage 3 and above
What is a Nurse Specialized in Wound, Ostomy and Continence Care (NSWOCC)?
Stoma that is pink or red, slightly moist, with intact peristomal skin free of irritation
What is a healthy stoma?
PI developed in the hospital if there is no documentation within 24 hours of admission that the PI was present
What is a Hospital Acquired Pressure Injury (HAPI)?
Minimum frequency of repositioning to prevent development of pressure injuries
Every 2 hours while in bed and every 1 hour while up in chair
Apply no-sting barrier wipe/spray, transparent film, change dressing every 5-7 days, offload pressure
Stage 1 PI Wound Care recommendations
Team member to consult for suspected poor oral intake contributing to malnutrition
What is a Registered Dietician?
Blotchy, diffused, irregular areas of erythema that occur with exposure to urine/feces/moisture
What is Incontinence-Associated Dermatitis?
Full thickness skin loss with visible adipose (fat) tissue, granulation tissue and epibole (rolled, wound edges)
What is a Stage 3 Pressure Injury?
Pressure injury prevention strategies
Protect the skin from moisture, reduce and limit layers, complete daily skin assessment
Name 3 wound care recommendations for Stage 2 PI
Cleanse with NS. May apply inadine OR adaptic. Cover with Tegaderm absorbent dressing or adhesive foam dressing such Mepilex
Point-of-care mobility assessment performed by this team member to determine PI risk factors
What is PT/OT?
Skin injury from use of device applied for diagnostic or therapeutic purposes that conforms to the shape of the device
What is a Medical Device Associated Pressure Injury?
Full thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone
What is a Stage 4 Pressure Injury?
Four offloading devices that can be used to prevent pressure injuries
What are pillows, foam wedges, air mattress, heel booties?
Wound care device that uses negative pressure designed for use in Stage 4 or above PI
What is VAC Wound Therapy
Suspected infected wound with purulent drainage can be assessed by this physician specialty
What is Infectious Disease (ID) physician?
Blister on a bony prominence that is deep purple/red in colour and can be filled with blood
A Localized area of NON-blanchable redness indicates Stage 1. An area of BLANCHABLE redness is NOT Stage 1
Lateral side-lying position coined by our very own ICU physician
What is the Redstone Turn?
Surgical, mechanical, chemical or autolytic removal of dead tissue to promote wound healing
What is debridement?
Three reasons why wound assessment is important
Guides treatment decisions, promotes wound healing and infection prevention, improves patient outcomes
Improving vascular flow, infection control, pressure downloading, and glycemic control
What is treatment of diabetic foot ulcers?