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have you any in service taining about pressure injuriy prevention and managment
Stage I pressure injuries are defined as intact skin with non-blanchable erythema in lightly pigmented persons.
Risk factors for development of pressure injuries are immobility, incontinence, impaired nutrition, and altered level of consciousness.
All hospitalized individuals at risk for pressure injuries should have a systematic skin inspection at least daily and those in long-term care at least once a week.
Hot water and soap may dry the skin and increase the risk for pressure injuries.
It is important to massage bony prominences
A Stage III pressure ulcer is a partial thickness skin loss involving the epidermis and/or dermis.
All individuals should be assessed on admission to a hospital for risk of pressure ulcer development.
A Stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure.
An adequate dietary intake of protein and calories should be maintained during illness.
Persons confined to bed should be repositioned every 3 hours.
A turning schedule should be written and placed at the bedside.
Heel protectors relieve pressure on the heels
Donut devices/ring cushions help to prevent pressure injuries.
In a side lying position, a person should be at a 30-degree angle with the bed unless inconsistent with the patient’s condition and other care needs that take priority.
The head of the bed should be maintained at the lowest degree of elevation (hopefully, no higher than a 30 degree angle) consistent with medical conditions.
A person who cannot move him or her should be repositioned every 2 hours while sitting in a chair.
Persons who can be taught should shift their weight every30minutes while sitting in a chair.
Chair-bound persons should be fitted for a chair cushion.
Stage II pressure injuries are a full thickness skin loss.
The epidermis should remain clean and dry.
The incidence and prevalence of pressure injuries are so high that it would be better if the institution appoints a team to study risk factors, prevention, and treatment.
A low-humidity environment may predispose a person to pressure injuries.
To minimize the skin’s exposure to moisture on incontinence under pads should be used to absorb moisture.
Slough is yellow or creamy necrotic tissue on a wound bed.
Bony prominences should not have direct contact with one another.
Every person assessed to be at risk for developing pressure injuries should be placed on a pressure redistribution bed surface
Blanching refers to whiteness when pressure is applied to a reddened area.
A pressure redistribution surface reduces tissue interface pressure below capillary closing pressure.
Skin macerated from moisture tears more easily.
A pressure ulcer scar will break down faster than unwounded skin.
A good way to decrease pressure on the heels is to elevate them off the bed.
All care given to prevent or treat pressure injuries must be documented.
Devices that suspend the heels protect the heels from pressure.
Shear is the force that occurs when the skin sticks to a surface and the body slides.
Friction may occur when moving a person up in bed.
A low Braden score is associated with increased pressure ulcer risk.
Stage II pressure injuries may be extremely painful due to exposure of nerve endings.
For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals.
Educational programs may reduce the incidence of pressure injuries.
Do you screen all patients for pressure ulcer risk upon admission.
Do you screen all patients for pressure ulcer risk upon readmission.
Do you screen all patients for pressure ulcer risk when condition changes
Do you assess the skin intactness in order to prevent occurency of pressure injury up on addmission
Do you assess the skin's color in order to prevent occurency of pressure injury up on addmission
Do you assess the skin's sensansion in order to prevent occurency of pressure injury up on addmission
Do you assess the temperature of skin in order to prevent occurency of pressure injury up on addmission
Do you assess the skin's moisture in order to prevent occurency of pressure injury up on addmission
Do you assess a patient at risk of developing pressure injuries using Braden scale?
Do you assess a patient at risk of developing pressure injuries using Norton scale?
Do you assess a patient at risk of developing pressure injuries using Water low scale?
Do you relieve the skin's pressure ulcers by supporting the patient's body using air bed mattress?
Do you relieve the skin's pressure ulcers by supporting the patient's body using a chair?
Do you relieve the skin's pressure ulcers by supporting the patient's body using Pillow?
Do you relieve the skin's pressure ulcers by supporting the patient's body using Repositioning?
Do you assist a patient with impaired mobility by turning his/her position every 2hours?
Do you assist a patient with impaired mobility by rising his/her head from the bed below 30 degree?
Do you assist a patient with impaired mobility by encouraging ambulation (within the patient’s limit)?
Do you develop a toileting plan to manage the patient's fecal incontinance?
Do you check for the patient's soiling to manage the patient's fecal incontinance?
Do you assist the patient with hygiene at the time of soiling to manage the patient's fecal incontinance?
After diagnosing of fecal incontinance do you treat its causes?
Do you develop a toileting plan to manage the patient's urinary incontinance?
Do you carry out wet checks for the patient with urinary incontinence?
After diagnosing of urinary incontinance do you treat its causes?
Do you assist the patient with hygiene at the time of soiling to manage the patient's urinary incontinance?
Do you using the skin barriers and protectantsassist to manage the patient's urinary incontinance?
Do you improve the patient nutritional needs by providing him/her with supplements (protein, Vitamin A and C for malnourished patients)?
Do you provide feeding assistance to the patient?
Do you ansure the patient is taking adequate fluid ?
Do you consult a dietitian to improve the patient nutritional needs?
Do you provide health education on pressure injury preventive measures to the patient and his/her caregiver during hospitalization?
Do you provide health education on pressure injury preventive measures to the patient and his/her caregiver before discharge?
Poor access to literature and reading facilities
Heavy workload and inadequate staff
Lack of universal guide line on prevention of pressure injury
Inadequate training coverage of pressure injury prevention
Uncooperative patients
Lack of job satisfaction in nursing profession
Presence of other priorities than pressure injury
Shortage of resources (equipment/resource)
Inadequate knowledge about pressure injury among nurses
Lack of multidisciplinary among staff nurses
I don’t have any challenge
Level of knowledge
Level of knowledge in ranges
Level of practice