Non-blanchable erythema (usually over a bony prominence, but not always) after offloading for 30 minutes or greater.
What is a Stage I Pressure Ulcer
100
I am a wound treatment that can be used for prevention or as a secondary dressing (to cover a wound). I am tan/brown in color and made of foam. I require an order to be applied. I come from SPS.
What is Mepilex foam dressings.
100
I am a first line barrier cream/ointment that comes from SPS. I can be applied with "nursing judgment" in an incontinent or at risk Veteran. I go on clear so can easily see/inspect the skin through a thin layer of application.
What is Aloe Vesta Moisture Barrier Ointment.
100
The three most common types of ostomies seen here at Cleveland VA/Wade Park are:
What is an ileostomy, a colostomy or an ileal conduit (urostomy).
100
Education staff and Veterans to keep tubing secured, especially NG tubes, Dobhoffs, foley catheter tubing, and fecal management system (Flexi-Seal) to prevent this type of pressure ulcer/injury.
What is a Mucosal Pressure Ulcer/Injury (MPU)
200
Full-thickness tissue loss; SQ tissue may be visible but bone, tendon or muscle are not exposed. Slough may be present in the wound bed but does not obscure the true depth of the wound.
What is a Stage III Pressure Ulcer/Injury
200
I am a barrier cream that comes from pharmacy that is often used to treat fungal contact irritant dermatitis. I require a prescription. I cannot be kept at the bedside.
What is Baza AF Barrier Cream (Miconazole)
200
If a Veteran is sitting for prolonged periods in a wheelchair or Broda/recliner chair, please consult with your Charge Nurse or OT department to obtain this.
What is a wheelchair cushion for prevention as well as pressure mapping if a Roho.
200
Ostomy pouches should be emptied when they are how full?
What is 1/3-1/2 way full - this will prevent the pouch from getting heavy and pulling away from the skin, which will in turn prevent leakage.
200
Educate nursing assistants and other supportive staff to notify the RN if they notice what appears to be a bruise or purple discoloration over a bony prominence because this could indicate...
What is a Deep Tissue Injury
300
Superficial or partial tissue loss of dermis presenting as a shallow ulcer with a red/pink wound bed. Slough is not present. May also present as intact or clear fluid-filled blister.
What is a Stage II Pressure Ulcer/Injury
300
I am used as an "advanced wound treatment modality" in heavily draining wounds which are uninfected (or infection is being treated) to promote healing and granulation tissue. I need to be plugged in to charge. I am typically changed 3x per week.
What is negative pressure wound therapy or Wound VAC
300
In order to prevent pressure ulcers in immobile Veterans, they should be turned and repositioned at a minimum how often?
What is every 2 hours.
300
If an ostomy pouch is leaking from the seal, it is okay to tape the borders to reinforce it... true or false?
What is False - you should never tape an ostomy pouch because the leak will continue underneath the tape and cause skin irritation and damage due to the acidic content of the output. If a Veteran complains of itching under the barrier this is a good indication that there is a leak and it needs to be changed.
300
What does H.A.P.U stand for?
What is Hospital Acquired Pressure Ulcer
400
Full thickness tissue loss with exposed bone, tendon and/or muscle. Slough may be present but does not obscure true wound depth. Can extend into supportive structures (fascia, joint capsule). Osteomyelitis should be considered.
What is a Stage IV Pressure Ulcer/Injury
400
I am a treatment that is commonly prescribed for stage III or IV pressure ulcers that contain slough. My main job is enzymatic debridement (getting rid of the slough). I come from pharmacy and am expensive - so please use me correctly! I am applied nickel-thick and typically changed every day.
What is Santyl.
400
It is okay to leave on a diaper or pull-up during the night or when napping for an incontinent Veteran... true or false?
What is False - diapers and pull-ups are moisture trapping. We use Ultrasorb pads here - one pad on the bed to wick moisture away from the body. No diapers while in bed!
400
I should be used to cleanse the peri-stomal skin in a Veteran with an ostomy.
What is non-lotion soap and water. Do not use the peri-wipes (Barrier Shield wipes) - they contain dimethicone which is a lotion - your pouch will not adhere to the skin. Do not cleanse with any soaps containing lotions or fragrances - it will cause a leak.
400
What is the evidence based tool used here at Wade Park VA Medical Center by nursing to predict a Veteran's risk for pressure ulcers/injury or skin breakdown?
What is The Braden Scale
500
Full thickness tissue loss in which the wound base is covered >75% by slough (tan, yellow, brown, gray necrotic tissue) or eschar. The wound bed is unable to be visualized or staged.
What is an Unstageable Pressure Ulcer/Injury.
500
I am a treatment that is commonly used for radiation burns (or other burns). I come from pharmacy and require a prescription. I should not be used in Veterans that have sulfa allergies. I should not be used in those actively undergoing radiation therapy because I contain silver and could cause a burn. I may be applied daily or BID.
What is Silvadene Cream.
500
I am a lab value that is oftentimes used to predict a Veteran's nutritional status and my reference range here is 12-40. A (blank) below 12 indicates malnutrition and poor ability to heal wounds.
What is Prealbumin.
500
This is how often the typical ostomy pouch should be changed.
What is biweekly (Mon/Thurs or Tues/Fri, etc.). If an ostomy pouch is being changed more than biweekly or leaking often, notify your WOC nurse - there are solutions!
500
A Veteran is allowed to keep creams from pharmacy such as Silvadene or Zinc Oxide 16% at the bedside... true or false?
What is False - no medications are to be kept at the bedside. This is important to remember as it is also a teaching point for OIG.