Pressure Ulcers
Lower Extremity Wounds
Wound Management Protocol
Preventing Infection
POO-Pourri
MASD
100
Stage this wound 
What is a Stage 3 PI
100
What type of foot ulcer is this? 
What is a diabetic foot ulcer
100
Partial and full thickness wounds with minimum exudate/ rehydrates the wound bed/ not recommended for moderate or heavy exudate
What is Hydrogel?
100
What I should wear if anticipating splashes or sprays or potential contamination of my clothing during a dressing change
Full PPE including gown gloves and eye protection IF needed
100
Is everyone's responsibility
Preventing pressure injuries
100
MASD is skin damage caused by prolonged exposure to
What is moisture - such as urine, feces, saliva, wound exudate, mucous, moisture at stoma sites, and perspiration
200
Stage this wound 
What is Unstageable
200
Usually painless, these wound form due to poor perfusion and tend to be irregular shaped and "weepy"
What is a vascular ulcer
200
Full thickness wounds with minimal to moderate exudate
What is collagen dressing or particles
200
What infection might this resident have or has had recently? 
What is Covid 19, what are covid toes?
200
Tasks that should be turned one for prevention of skin breakdown in at risk residents
What are turning/ positioning, elevating heels
200
Skin irritant usually related to wound exudate to surrounding area
What is periwound maceration
300
Clear fluid filled blister on heel
What is a Stage 2 PI
300
Often appear "punched out", these ulcers also form due to poor perfusion and are usually painful and often found on the tips of toes, ankles and heels
What is an arterial ulcer
300
Ropes of this product should be used for tunneling and undermining wounds with moderate to heavy drainage
Calcium alginate
300
Signs and symptoms of infection
What is swollen and red, throbbing with pain, feel warm, increased drainage, purulence
300
The minimum number of rounds that should be done per shift
What is 2 xs daily or 2
300
Barrier ointments/ creams are one intervention to consider for this type of dermatitis
What is incontinence associated dermatitis?
400
Blood filled blister
What is unstageable
400
ABI compares BP measured at the ankle to the BP measured at the arm. A low number can indicate narrowing or blockage of the _____________ in the legs
What is arteries
400
Protect and Offload, leave it alone, maybe apply skin prep, apply moisturizer to unaffected skin around this daily to 2xs a day
What is dry intact eschar on heels
400
Every order for a wound dressing should also have a
What is a daily monitoring order
400
Types of prevention devices
What are heels up cushions, prevalon boots, wheelchair cushions, foam positioning cushions, Roho cushions
400
This type of dermatitis often presents as a "mirror image" erythema of both sides of skin area
What is intertriginous dermatitis
500
Will never have slough in wound bed
What is a stage 2 PI
500
Type of test that is often ordered for to rule out one thing, but can also be used to check with issues of blood flow in both veins AND arteries
What is a Doppler study
500
Recommended type of dressing for stage 2 PI
What is hydrocolloid
500
Number of times hand hygiene is performed during a dressing change
What is at least 3
500
Should be entered into Risk Management to assist with tracking for QAPI
What is any new facility acquired pressure injury
500
Name this dermatitis 
What is peristomal dermatitis
600
Continuous rubbing or sliding of a surface along the skin can result in redness, inflammation or a wound referred to as a
What is a friction blister
600
Normally forms below the ankle of a resident and skin necrosis and gangrene can also possibly be included
What is a diabetic or neuropathic wound
600
Full thickness wound with slough - type of dressing to achieve autolytic debridement
What is collagen, hydrogel, calcium alginate or honey alginate
600
Remove devitalized tissue, decrease bacterial burden, remove exudate, prevent harm to healthy tissue
What are the goals of wound cleansing
600
As a high risk care are, ___________________ may be chosen as an annual performance improvement project
What is pressure injury prevention?
600
Name this dermatitis 
What is incontinence associated dermatitis