patient safety II

Question 1

Henrich II Fall Risk Model

Answer 1

> 5 = high risk of falling

Question 2

pressure intensity

Answer 2

minimal pressure required to collapse a capillary. Tissue ischemia or reduction of blood flow can occur when there is a prolonged period.

Question 3

pressure duration

Answer 3

low pressures over a long period of time and high-intensity pressures over short periods of time both cause tissue damage. Extended periods of time occlude blood flow and nutrients, contributes to cell death.

Question 4

tissue tolerance

Answer 4

the ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structure. The factors of shear, friction, and moisture affect the skin’s ability to tolerate pressure.

Question 5

5 classic signs of wound infection

Answer 5

1. pain or tenderness
2. erythema (redness) or edema (swelling)
3. purulent discharge
4. fever and/or chills
5. warmth around wound site

Question 6

Braden scale 15-18

Answer 6

at risk

Question 7

Braden scale 13-14

Answer 7

moderate risk

Question 8

Braden scale 10-12

Answer 8

high risk

Question 9

Braden scale 9>

Answer 9

very high risk

Question 10

stage 1

Answer 10

reddish, non-blanchable erythema

Question 11

stage 2

Answer 11

open, bed of wound is visible, pink or red, and moist
can present as an intact or burst blister

Question 12

stage 3

Answer 12

adipose (creamy and shiny) is visible
granulation tissue
slough, eschar, or both is seen
undermining or tunneling can occur

Question 13

stage 4

Answer 13

exposed fascia, muscle, tendon, ligament, or bone
slough, eschar, or both is seen
epibole (rolled edges)

Question 14

unstageable

Answer 14

eschar/ slough obscures the ulcer

Question 15

body mechanics

Answer 15

1. Tighten your abdominal muscles. Keep your back, neck, pelvis, and feet aligned (6 check points). Avoid twisting.
2. Bend at knees and keep feet wide apart. Lower center of gravity.
3. Use your arms and legs and NOT your back.
4. Slide the patient toward your body. Sliding takes less effort than lifting. (note to self: use a pull sheet to minimize shearing of the patient’s skin).
5. If there are multiple people, the person with the heaviest load coordinates the effort by counting to three. All together = lighter load for everyone