Assisting W/ Positioning/transferring Flashcards
Bony prominences
Areas where thin layer of fat and muscle between skin and the bone or cartilage underneath
Skin breakdown
Loss of healthy intact skin because tissue not getting enough oxygen and nutrients
Friction
Occurs when two surfaces rub against each other causing pressure ulcers
Shearing
Is when a surface moves one way against another surface that offers resistance like dragging
1st stage of pressure ulcers
Area is red
Pale or dark
Normal color does not return to normal color quickli
2nd stage of pressure ulcers
The area looks shallow open ulcer with pink or red exposed tissue at the bottom
Sometimes instead of an ulcer. Looks like blister
Stage 3 of pressure ulcer
More tissue lost
Fat beneath skin may be visible
Stage 4 of pressure ulcers
Deep crater forms
Muscle or bone may be visible
Risks for pressure ulcers
Immobility
Advanced age
Fragile dry skin
Moisture
Poor nutrition
Poor hydration
Poor circulation
Poor oxygenation
Pressure ulcer
Sore that develops from hard surface
Pressure ulcers can be caused in these area:
Back of head Ear Shoulder Elbow Tailbone Knee ankle Heel
Risk factors for pressure ulcer development
Immobility
Advanced age
Fragile dry skin
Moisture I.e where skin surfaces touch another
Or skin in contact with soiled line so/clothes
To prevent direct pressure what is done
Change persons position every 2 hours Observe and report any reddened skin Ensure body is in good alignment Use pressure reducing devices like mattresses,heel and elbow pads Remove any hairpins when resting head
To prevent friction and shearing injuries
Get help to shift person by lifting up Elevate head no more than 30 degrees Make a tight wrinkle free bed Prevent medical equipment from rubbing against person Pad supportive devices Ensure shoes and socks fit well
Protecting skin to skin contact
Check skin for changes under the folds
Position person so air circulates around arms and legs to keep skin from skin
To prevent moisture from causing pressure ulcers
Wash, rinse, dry kin thoroughly
Check people with incontinence ever 2 hour to keep skin, clothing and linens clean and dry
Cover vinyl chair with pad or sheet
Have person wear moisture absorbing clothes from natural fabrics
To prevent poor circulation to be cause of pressure ulcers
Elevate persons arms and legs
Provide gentle massage
Observe skin frequently and report any changes to nurse
To improve the persons skin
Nutrition and hydration.
Encourage person to eat a well-balanced diet
Encourage to drink adequate amt of fluids
To improve persons skin
S
Mobility
Reposition person often
If person is able assist person transferring out of bed and walking
Pressure ulcers prevention
Good skin care Encouraging movement Observe signs of skin breakdown Regular toileting and perineal care Good nutrition and fluid intake Assisting with repositioning and avoiding friction and shearing injuries Ensure wrinkle free linens
Supine position
Bed flat Person on back, head supported by pillow Small pillow to back Arms extended to sides Palms down Toes pointed out Pressure off heels pillow calves and ankles
Fowler’s position
In supine position But head of bed raised 45 degrees Sitting up Low fowler=30 degrees High fowler=90 degrees Fowler should be short time only. Person tends to slide down causing shearing injuries. People slide down bed. People on tailbone=pressure ulcer formulation
Sims position
Exaggerated side-lying position
Used for rectal thermometer to giving an enema
Top leg is bent at knee,supported by pillow
Top arm bent at elbow with hand near face and supported by pillow.
Log rolling
Done when resident has spinal injury
