Immobility

Question 1

What tool would you use to assess for skin injury?

Answer 1

Braden Scale and Norton Scale (score <14 = higher risk for pressure injury)

Question 2

What does the Braden Scale look for when assessing?

Answer 2

• sensory
• moisture activity
• mobility
• nutrition
• friction & shear
  (low score = good; high score = more risk for skin breakdown)

Question 3

What causes decubitus ulcers?

Answer 3

• prolonged pressure
• shear & friction damage to skin
• moisture

Question 4

What are the risk factors for decubitus ulcers?

Answer 4

• immobility
• poor nutrition & hydration
• co-morbidities
• age-related skin changes

Question 5

When do you notify the provider?

Answer 5

• new bleeding
• changes in LOC, VS, breathing
• new pain in the extremities
• Unable to detect a pulse (after doppler)