Exam 3 Flashcards
Making an occupied bed
It is only made if the patient cannot get out of bed.
Bed linens should be neat, orderly and wrinkle free.
Hygiene
It is the proper care of the skin, hair, nails and teeth to promote good health by protecting the body from infection and disease
Patient safety
Risk factors for falls
Ambulating a patient
Transferring a patient
Have patient dangle their legs on the side of the bed
Braden Scale
A scale for predicting pressure sore risk. Most commonly used
Dermis
The inner, thicker layer that is made of dense connective tissue that gives the skin strength and elasticity
Epidermis
The outer, thinner layer that consists of stratified squamous epithelial tissue and does not contain blood vessels
Stages of pressure injuries
Stage 1: intact skin that is red, deep pink, or mottled skin that does not blanch with fingertip pressure
Stage 2: Partial thickness skin loss with exposed epidermis
Stage 3: Full thickness skin loss that looks like a deep crater and may extend to the fascia
Stage 4: Full thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures
Unstageable: Loss of full thickness of tissue
Deep Tissue Pressure Injury: Localized discolored intact skin that is maroon or purple or a blood filled blister resulting from damage to underlying soft tissue from pressue or shearing
Decreasing pressure injuries
Change position q2h
Keep heels of immobile patients off the bed
Avoid positioning patient directly on the bony prominences
Minimize friction and shearing
Use a pressure reducing bed or pressure pad
Use a pressure reducing device in the chair for chair bound patients. Reposition every hour
Do not massage reddened skin
Wash and dry after incontinence episodes
Avoid injury due to improperly fitting casts, splints braces, etc
Avoid burns caused by excessively hot or cold applications
Adequate nutrition and fluid intake
Sentinel events
An unexpected patient care event that results in death or serious injury to the patient
Material Safety Data Sheets
Alarm fatigue
When nurses become desensitized to patient care alarms and then miss or delay response to an alarm
Use of a fire extingusher
PASS
Pull the pin
Aim at the base of fire
Squeeze the trigger
Sweep side to side
or RACE
Rescue any patients in immediate danger
Activate the fire alarm system
Contain the fire
Extinguish the flames or Evacuate
