FINAL EXAM Flashcards
What are 5 factors that can contribute to a falls risk?
- Falls in past year
- Impaired cognition/sensory perception
- Incontinence
- Wandering
- Improper footwear
What are the 6 components of the morse falls scale?
- Falls in past 3 months
- Secondary diagnosis
- Ambulatory aid
- IV
- Gait/transferring
- Mental status
What are 4 guidelines to documentation to keep you out of trouble?
- Documentation is proof of your care
- Nothing written, nothing done
- You will be judged by how you document
- Keep documenting until issue resolved
Why might immobility result in elevated nitrogen levels?
Amino acid breakdown
Why might immobility result in hypercalcemia?
Bone resorption
What is the term for alveolar collapse due to bronchial/bronchiolar blockage?
Atelectasis
What kind of lung infection may result from immobility?
Hypostatic pneumonia
What blood pressure difference defines orthostatic hypotension?
> 20mmHg systolic or >10mmHg diastolic
Which topical medication is used for ischemic heels?
Proviodine
What angle should HOB be kept at to prevent pressure injury?
<30 degrees
What angle should the knee gatch be kept at to prevent sliding down?
10-20 degrees
What are 3 factors that contribute to pressure injury development?
- Intensity
- Duration
- Tolerance
What is the term for the minimum amount of pressure required to collapse a capillary?
Capillary closing pressure
What is the term for skin fold dermatitis?
Intertriginous damage (ITD)
What are the 6 areas assessed on the Braden scale?
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/shear
Define a suspected deep tissue injury (3)
- Persistent nonblanching deep red, maroon, or purple
- Epidermal separation revealing dark wound bed
- Blood filled blister
Define a stage 1 pressure injury
Nonblanching erythema
Define a stage 2 pressure injury (2)
- Partial thickness skin loss, exposed dermis
- Pink/red and moist wound bed, or serum filled blister
Define a stage 3 pressure injury (3)
- Full thickness skin loss
- Fat visible
- May have granulation, epibole, eschar, slough, undermining/tunneling
Define a stage 4 pressure injury
Exposed/palpable fascia, muscle, tendon, ligament, cartilage, bone
Define a stage 4 pressure injury
Exposed/palpable fascia, muscle, tendon, ligament, cartilage, bone
Define an unstageable pressure injury
Cannot be assessed due to obscuration by slough/eschar
Name 8 components of a wound assessment
- Anatomical location
- Size
- Wound bed
- Wound edges
- Peri-wound skin
- Exudate
- Edema or induration
- Pain
What terms are used to describe wound edges?
Epithelialization, epibole
