306 Exam (final Chapters) Flashcards
Top sites for pressure injury risks
Heels
Ankles
Hips
Sacral area
Elbows
Shoulders
Inside of knees
Occipital
Ears.
What 6 things does the Braden scale assess In pressure injuries
Sensory
Moisture
Activity
Mobility
Nutrition
Friction and shear
If a patient score a 9 or less on the Braden scale what does that mean?
They are at a very high risk of getting a pressure injury
If a patient scores in between 19-23 on the Braden scale what does it mean?
Not much of a risk at all of getting a pressure injury
How many layers deep is the epidermis over the palms of hands and soles of feet?
Over the rest of the body?
5 layers over palms of hands and soles of feet.
4 layers over the rest of the body
Which layer of skin consists of the papillary layer and the reticular layer?
(This layer also contains the hair follicles and eccrine sweat glands)
The dermis.
What layer of skin contains nerves, arteries and veins.
It also contains adipose tissue.
Subcutaneous tissue
What internal factors can influence the appearance of skin and skin integrity?
Age
Genetics
Individuals underlying health
What is vernix caseosa ?
The protective covering on newborn skin in utero.
Excessive body heat increases the metabolic rate and the cells need for oxygen. T/f
True. And it puts client T risk for pressure injuries.
What laboratory test should you anticipate being prescribed for a patient with a stage 3 pressure injury that reports pain at the site which has developed a yellow-white exudate?
Complete blood count.
This would indicate if there was an elevated white blood count which would point to a possible infection and used to determine the degree of inflammation.
What dressing would you use for a pressure wound with deep exudate that will form a gel when in contact with the wound exudate?
Alginate dressings form a gel when in contact with wound exudate.
Should bony prominences be massaged to help prevent pressure wounds?
No.
What is Granulex?
A product that increases blood supply to the intact skin of stage 1 pressure injury. It toughens skin, adds moisture, and contains trypsin to aid in removal of necrotic tissue.
Petroleum lotions or ointments should be avoided. T/f?
True
Even slight weight shift of only 10-15 degrees every 15-30 minutes can help promote circulation. T/f?
True
What does larval therapy do for a pressure ulcer?
They decrease bacterial growth and break down necrotic tissue while keeping healthy tissue intact.
What kind of debridement causes the least damage to healthy and healing tissue surrounding the pressure injury?
Autolytic debridement
A patient with diabetes mellitis has a blister on the left heel caused by Ill fitting shoes. What stage should you document this injury to be?
Stage 2
A patient has a pressure injury over the sacrum. What assessment finding would indicate that this is a stage 3 injury?
Necrosis of subcutaneous tissue.
What assessment finding of a wound would indicate it as a stage 4 injury?
Exposed muscle and bone.
For patients who are confined to bed, what kind of support surface should be used?
A kinetic bed that provides oscillation therapy.
If a patient presents with a lower limb that is dusky red colored when the limb is lowered, what does this suggest
Arterial insufficiency
If a patient has cool skin to the touch and mild edema, and dependent rubor. What would this suggest.
Arterial insufficiency
A blood lactic acid level is commonly measured to identify what?
Possible sepsis
Impetigo is an infectious bacteria skin condition.
T/f
True
A superficial skin infection common in children that presents as an itchy rash with clusters of fluid filled vesicles that rupture easily. Common on face, arms, and legs.
Impetigo
Otoacoustic emissions testing is for what?
Newborn and infant hearing screening.
Risk factors for cataracts
Age
Genetics
Sunlight exposure
Smoking
Alcohol
Eye trauma
Diabetes
Corticosteroids
Primary prevention
Methods designed to focus on health promotion and illness prevention
Secondary prevention
Methods that focus on the diagnosis and treatment of disease.
Tertiary prevention
Methods that focus on restoration of health following an Illness or accident. Like rehab or palliative services.
What is the relationship of nutrition to pressure injury development
Poor dietary intake of kilocalories, protein, and iron can increase the risk of pressure injuries.
A client has a pressure injury on the right elbow that is covered with eschar and extensive tissue damage. What stage is this?
UNSTAGEABLE.
(A stage 4 pressure wound may be covered in eschar but cannot be evaluated if wound bed is obscured with extensive tissue damage)
Eschar is not present in stage 2.
Stage 3 might have eschar with tissue damage limited to subcutaneous tissue.
A patient has a localized purple discoloration that does not blanch over the coccyx. What pressure injury would be suspected?
Deep tissue injury
(Does not blanch. Skin intact. Thin blister or eschar can develop very quickly)
