Exam Of Bedridden, Hospitalized, Or Disbaled Patient Flashcards
What are the transfer guidelines
- Allow the patient to direct the transfer
- Do not overestimate ability to lift
- Not all non ambulatory people need assistance
- Keep back straight, bend at knees and lift with legs
- Be aware of jewelry, clothing, tubing
What are some causes of autonomic hyper/dysreflexia
- Seen in patients with spinal cord injuries (T6) (stimulation of the bladder will cause this)
*high BP
*Sweating
*blotchy skin
*nausea
*cutis anserine
What should you examine on al hospitalized patients
- Do a leg and catch exam
*risk of DVT
“No calf erythema, swelling or tenderness”
What is a pressure injury
- Localized injury to the skin or underlying tissue
*usually over a bony prominence
What are the predisposing factors to a pressure injury
Intrinsic
*limited mobility, poor nutrition, comorbidties, aging skin
Extrinsic
*pressure, friction, shear, moisture
How to prevent pressure injuries
- Bedridden patients should be repositioned every 2 hrs
*complete a nutritional assessment, will help with wound prevention and healing
What is stage one and 2 on pressure injuries
1
*intact skin with non blanching redness
2.
*shallow, open ulcer with red-pink wound bed
What is stage III and IV of pressure injuries
3
*full thickness loss with visible subcutaneous fat
4
*full thickness tissue loss with exposed muscle and bone
What classifies a pressure injury as unstageable
- Slough over top
*cannot tell how deep it is
*is not infected
What is a suspected deep tissue injury
- Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and or shear
*cannot stage
*will open up eventually
How to document size of a pressure injury
Patients head is 12 o’clock
1. Length X width X depth
L = 12 to 6
W = 3 to 9
Depth = straight depth
*measure in cm
What will epithelial and granulation tissue look like on a pressure injury
E: new skin, light-pink and shiny
G: pink or red, “Cobblestone”, bleeds easily
*good sign getting vascular supply
What will slough and fibrinous tissue look like on a pressure injury
Slough
*non-viable, yellow, tan, grey, green or brown
*mucinous in texture
Fibrinous
*prior to wound opening
*white or grey
What will necrosis or Eschar formation look like?
- Dead or devitalized tissue
*hard, black, brown
*scab like
*cannot stage, scab needs to come off
What is tunneling
- Passage way of tissue destruction under the skin surface opening at skin level
