2E: Assessing Screening for Pressure Ulcer RiskBackground: The purpose of this tool is to determine if your facility has a process to screen patients for pressure ulcer risk. The tool is one of a series of Facility Assessment Checklists developed to identify areas that need improvement. Show
Reference: Quality Partners of Rhode Island. Pressure Ulcers: Facility Assessment Checklists. Available at: https://www.qualitynet.org/dcs/ContentServer?cid=1098482996140&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools. Instructions: Complete the checklist. For certain questions, you may want to consult with appropriate staff in your organization. Use: Use the results of this assessment to identify issues that you need to deal with, and formulate goals for your pressure ulcer prevention initiative. Assessment of Screening for Pressure Ulcer Risk Does your facility have a process for screening that addresses all the areas listed below?
Top of Page 2F: Assessing Pressure Ulcer Care PlanningBackground: This tool can be used to determine if your facility has a process for developing and implementing a pressure ulcer care plan for patients who have been found to be at risk or who have a pressure ulcer. The tool is one of a series of Facility Assessment Checklists developed to identify areas that need improvement. Reference: Quality Partners of Rhode Island. Pressure Ulcers: Facility Assessment Checklists. Available at: https://www.qualitynet.org/dcs/ContentServer?cid=1098482996140&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools. Instructions: Complete the checklist. For certain questions, you may want to consult with appropriate staff in your organization. Use: Use the results of this assessment to identify issues that you need to deal with, and formulate goals for your pressure ulcer prevention initiative. Assessment of Pressure Ulcer Care Plan Does the care plan for pressure ulcers address all the areas below (as they apply)?
* To determine if a patient has bottomed out, the caregiver should place his or her outstretched hand (palm up) under the mattress overlay below the existing pressure ulcer or that part of the body at risk for pressure formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient has bottomed out. Top of Page 2G: Pieper Pressure Ulcer Knowledge TestBackground: This tool can be used to assess staff knowledge on pressure ulcer prevention. The 47-item test was developed by Pieper and Mott in 1995 to examine the knowledge of nurses on pressure ulcer prevention, staging, and wound description. Questions 1, 3, 15, 29, 33, and 40 have been modified from the original to make it more specific to hospital care. Reference: Pieper B, Mott M. Nurses' knowledge of pressure ulcer prevention, staging, and description. Adv Wound Care 1995;8:34-48. Instructions:
Use: Mean scores on this test are usually analyzed. Analyze the test results. If you find gaps of knowledge, work with your education department to develop and tailor educational programs that address these items. Pieper Pressure Ulcer Knowledge TestFor each question, mark the box for True, False, or Don't Know.
Pieper Pressure Ulcer Knowledge Test: Answer Key
Top of Page 2H: Pressure Ulcer Baseline AssessmentBackground: The purpose of this tool is to assess general staff knowledge on pressure ulcer prevention. It is shorter than the Pieper but has not been as widely used. The tool is available on the Web site of the Institute for Healthcare Improvement. Reference: Adapted from: Iowa Health Des Moines. Pressure Ulcer Baseline Assessment. Available at: http://www.ihi.org/NR/rdonlyres/F2EF9AB3-BB0F-4D3D-A99A-83AC7E0FB0D3/6224/IowaHealthDesMoinesPUBaselineAssesment.pdf. Instructions: Administer the questionnaire to registered nurses and nursing assistants. The survey may need to be modified if certain questions are not consistent with your policies and procedures. Use: Use the findings to assess gaps in knowledge. Work with your education department to tailor specific education programs to the needs of your staff. Pressure Ulcer Baseline Assessment for Registered Nurse For which factors in the Braden Scale are you evaluating the patient's ability to respond to verbal command? A. Activity Minimally, a patient in the acute care setting should be assessed for pressure ulcer risk at least every: A. 48 hours How often should you, the RN, assess and document skin condition? A. Daily What can you, the RN, do when one of your patients has discoloration of the skin (red, purple, blue) indicating pressure? A. See what happens over the next 24 hours. Who is the primary person accountable for patient skin assessment, pressure ulcer prevention, and documentation? A. WOC Nurse (ET nurse) Pressure Ulcer Baseline Assessment for Nursing Assistant What is the most common reason a patient gets a pressure ulcer? A. Patient is a smoker. How often should you look at every patient's skin to look for signs of redness or discoloration? A. Daily, when patient bathes. The correct procedure for checking an air mattress every shift is A. Push down and if it feels soft it is OK. What should you report to your patient's RN every shift? A. Skin tears Pressure Ulcer Baseline Assessment: Answer Key Registered Nurse For which factors in the Braden Scale are you evaluating the patient's ability to respond to verbal command? A. Activity Minimally, a patient in the acute care setting should be assessed for pressure ulcer risk at least every: A. 48 hours How often should you, the RN, assess and document skin condition? A. Daily What can you, the RN, do when one of your patients has discoloration of the skin (red, purple, blue) indicating pressure? A. See what happens over the next 24 hours. Who is the primary person accountable for patient skin assessment, pressure ulcer prevention, and documentation? A. WOC Nurse (ET nurse) Nursing Assistant What is the most common reason a patient gets a pressure ulcer? A. Patient is a smoker. How often should you look at every patient's skin to look for signs of redness or discoloration? A. Daily, when patient bathes. The correct procedure for checking an air mattress every shift is A. Push down and if it feels
soft it is OK. What should you report to your patient's RN every shift? A. Skin tears Top of Page 2I: Action PlanBackground: The purpose of this tool is to provide a framework for outlining steps that will be needed to design and implement the pressure ulcer prevention initiative. Reference: Adapted from material produced by MassPro, a participant in the Centers for Medicare & Medicaid Services Quality Improvement Organization Program. Instructions:
Use: Use the completed sheet to plan, manage, and carry out the identified tasks. The plan should guide the implementation process and can be continually amended and updated. A sample completed form is shown below, followed by a blank form. Pressure Ulcer Prevention Action Plan Date: February 16, 2011 Improvement Objective: Implement standard pressure ulcer prevention practices within 6 months.
Pressure Ulcer Prevention Action Plan Date: ________________________ Improvement Objective:
Which would be considered a Stage 2 pressure injury?At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid.
Which stage of pressure injury can be dressed with a transparent or hydrocolloid dressing?Semi-transparent hydrocolloid dressings may be used over reddened skin (Category/Stage I pressure ulcers) as it is possible to observe for deterioration without removing the dressing.
Which type of dressing is used for a stage 3 pressure ulcer?Alginate dressings, which have many of the same properties as foam, are another choice for Stage III pressure ulcers. Both dressing types maintain a moist wound environment and may be used for tunneling and undermining.
Which one of the goals for wound care should be prioritized for a Stage 2 pressure ulcer?The goal of care for stage 2 pressure ulcers is to cover, protect, and clean the area. As always, decreasing pressure on the area is key to wound healing. With quick attention, a stage 2 pressure ulcer can heal very rapidly. Emphasis should be placed on proper nutrition and hydration to support wound healing.
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Which dressing would be inappropriate for a patient with a clean stage 2 pressure injury Quizlet
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