Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

skin integrity > skin assessment/braeden scale > Flashcards

skin assessment/braeden scale Flashcards

1
Q

what is the purpose of the skin?

A

protection
sensory
vitamin D synthesis
fluid balance
natural flora

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

whenever you inspect the body what specific things are you looking for?

A

bony prominences
visual and tactile assessments
rashes or lesions
hair distribution
skin color
blanch test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

in pediatric patients what bony prominence are you most likely to notice skin breakdown?

A

the back of the head

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

in geriatric patients what bony prominence are you most likely to notice skin breakdown?

A

sacral/coccyx area

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what patients are at higher risk for skin breakdown?

A

older patients
bed bound
diabetics
critically ill

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

during a skin assessment what do you want to focus on?

A

level of sensation
movement
continence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

what are the time intervals you would want to perform skin assessments on your patients?

A

high risk patients
every 4 hours or more
already compromised skin
every 1-2 hours
non risk patients
on admission
once by each shift

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what are the six aspects of skin integrity that we rate on the bradan scale?

A

sensory perception
moisture
activity
nutrition
mobility
friction and sheer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

within sensory perception if the patient can not communicate their discomfort always and has a sensory impairment in 1-2 limbs what rate is this?

A

slightly limited

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

if there is sensory impairment over half of the body and painful stimuli what grade of sensory perception would that be?

A

very limited

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

when linens get changed at minimum once per shift what moisture level would this be categorized as?

A

very moist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

if a patient can never get out of bed what are they categorized as?

A

bedfast

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

a patient that is categorized as chairfast is limited to what activity?

A

ambulation is severely limited to non-existent
cant bear their own weight must be assisted

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

patients who walk short distances with or without assistance are categorized as what?

A

walks occasionally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

categorized as walks frequently patients can either do one option or the other what are those options?

A

walk outside the room at least 2 times a day or inside the room during the day at least once every 2 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

how do you describe adequate nutrition?

A

eats over 1/2 of the meals
usually takes a supplement
tube feeding or TPN probably meets nutritional needs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

even if ordered by physician only consuming clear liquids for 5 consecutive days is classified as what type of nutrition?

A

very poor nutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

a potential problem with friction and sheer is classified by…

A

minimum assitance and is able to move feebly
skin probably slides against sheets

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

a problem of friction and sheer is described by?

A

moderate to minimum assistance in moving
frequently slides down in bed or chair
spasticity, contractures leads to almost constant friction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what classifies a low risk patient according to the braden scale?

A

15-18
regular turning schedule
enables as much activity as possible
protects heels
manage moisture and friction/sheer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

what classifies a patient as moderate risk based off the braden scale?

A

13-14
regular turning schedule
enable as much activity as possible
protect heels
manage moisture, friction and sheer
position patient at 30 degree lateral incline using wedges or pillows

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

what classifies a patient as high risk based off the braden scale?

A

12 or less
regular turning schedule
enable as much activity as possible
manage moisture, friction and sheer
protect heels
position patient at 30 degree lateral incline using wedges or pillows
make small shifts in position frequently
pressure redistribution surface

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

what are some tissue integrity interventions you can implement?

A

frequent repositioning
sitting in chair for 2-hour intervals
keeping HOB at 30 degrees but no higher
keeping a written schedule of turning and positioning

24
Q

what is the interval protocol?

A

cleanse
hydrate (protect the skin)
alleviate pressure
nourish
treat

25
what are the four wound stages?
stage 1 nonblanchable redness stage 2 partial-thickness stage 3 full-thickness skin loss stage 4 full-thickness tissue loss unstageable/unclassified full-thickness skin or tissue loss-depth unknown
26
the inflammatory response is the sequential response to cell injury based off what?
neutralizes and dilutes inflammatory agent removes necrotic materials establishes an environment suitable for healing and repair
27
does inflammation always equal infection?
no inflammation is always present with infection, but infection is not always present with inflammation
28
what conditions does the inflammatory response occur with?
surgical wounds, other skin injuries allergies autoimmune diseases skin infections
29
what does the intensity of the response depend on?
extent and severity of the injury reactive capacity of the injured person
30
what occurs in a vascular response to inflammation?
increased capillary permeability fluid moves into tissue spaces initially serous fluid that eventually contains albumin pulls more fluid from vessels into tissue
31
what results from a vascular response?
redness heat swelling at site of injury and surrounding area
32
what occurs within the body during a cellular response to inflammation?
neutrophils and monocytes move through capillary wall and accumulate at site of injury bone marrow releases more neutrophils in response to infection elevated white blood cell count
33
local response to inflammation involves?
redness heat pain swelling loss of function
34
systemic response to inflammation involves?
increased WBC count malaise nausea and anorexia increased pulse and respiratory rate fever likely due to complement activity and release of cytokines
35
types of inflammation
acute healing in 2-3 weeks nuetrophils predominant cell type at site subacute same features but last longer chronic may last for years predominant cell types are lymphocytes and macrophages may result from changes in the immune system
36
what is the final phase of the inflammatory process?
healing regeneration repair
37
what are the 3 phases included in the primary intention of healing?
INITIAL PHASE 3-5 days, acute inflammatory response GRANULATION PHASE fibroblasts secrete collagen, the wound is pink and vascular risk for dehiscence and resistant to infection MATURATION PHASE AND SCAR FORMATION begins 7 days after injury, continues for months/years wound becomes stronger and mature scar forms
38
how does secondary intention healing occuring?
ulceration and infection have large amounts of exudate and wide irregular wound margins with extensive tissue loss edges cannot be approximated healing process is same as primary, inflammation may be greater wound may need to be debrided
39
tertiary intention occurs by what?
delayed primary intention due to delayed suturing of wound occurs when a contaminated wound is left open to heal from inside out
40
regeneration occurs in partial thickness wounds and heals the wound by?
inflammatory process occurs epithelial proliferation and migration reestablishment of epidermal layers
41
repair occurs within full-thickness wounds and heals the wound by?
hemostasis inflammatory phase proliferative phase maturation due to the injury extending into the dermis they heal by scar formation
42
what factors influence wound healing?
nutrition tissue perfusion infection age decreased function of macrophages leads to delayed inflammatory response in older adults
43
what are some complications that can occur during wound healing?
hemorrhage hematoma infection dehiscence evisceration
44
what are precautions to take for a redden rectal area?
cleanse dry thoroughly moisture barrier daily & PRN
45
what precautions do you take for redden skin between skin folds?
cleanse dry thoroughly place inner dry or dry AG textile in skin folds
46
what precautions do you take for redden heels?
position pressure off of heels elevate on pillows sage boot reduce friction
47
what precautions do you take for a redden coccyx or sacral area?
change position every 1-2 hours HOB 30 degrees unless contraindicated avoid excess moisture frequent peri care wrinkle free linen
48
how do you classify a skin tear?
wound caused by shear, friction, or blunt force can be partial or full thickness common in older adults and critically ill
49
how often should you assess the skin integrity of a patient?
every shift and on admission; unless already compromised skin integrity
50
what are the purpose of dressings?
protects from microorganisms aids in hemostasis promotes healing by absorbing drainage or debriding a wound supports wound site promotes thermal insulation provides a moist environment
51
what are types of dressings?
gauze transparent film hydrocolloid hydrogel foam composite
52
what are important comfort measures to take whenever changing a patients dressing?
administer analgesic medications 30 to 60 minutes before carefully remove tape gently clean around wound edges turn and position patient dressings carefully manipulate dressings and draisn to minimize stress on sensitive tissues date and time dressings turn and position patient dressings document
53
what is the enemy of wound healing and why?
dryness antimicrobial and antibacterial solutions can damage new epithelium and delay healing
54
what must you do to contaminated wounds?
they must be converted to clean wound before healing can occur debridement may be necessary dressings are available that can absorb exudate and clean the wound
55
whats the most common type of drain found to remove excess fluids?
jackson-pratt

skin integrity (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions