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Fundamentals HESI > Skin Integrity > Flashcards

Skin Integrity Flashcards

1
Q

As surface area increases, (blank) increases.

A

friction

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2
Q

Name 3 ways to decrease friction.

A
  • tell the patient to bend knees and lift hips
  • lift the patient rather than push
  • use a drawsheet or transfer board
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3
Q

localized injury to the skin and/or underlying tissue, usually over a bony prominence

A

pressure ulcer

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4
Q

most widely used scale for pressure ulcer risk

A

Braden Scale

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5
Q

six subscales of Braden Scale

A

sensory perception, moisture, activity, mobility, nutrition, friction/shear

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6
Q

(Braden Scale) The lower the total score, the (blank) the risk of pressure ulcers.

A

higher

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7
Q

Hospitals do not get reimbursement for…

A

Stage III and IV pressure ulcers

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8
Q

Red, blue, mottled skin means…

A

impaired circulation

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9
Q

Change position every (blank) hours.

A

2

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10
Q

If the patient is totally immobile, keep the (blank) off the bed.

A

heels

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11
Q

If the patient is in a chair, they should be repositioned…

A

every hour

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12
Q

If the patient is in a chair, encourage self weight shifting every…

A

15 minutes

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13
Q

Do not massage (blank) and (blank).

A

red skin, bony prominences

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14
Q

head of the bed raised to 45 degrees or more

A

Fowler’s

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15
Q

Use Fowler’s position for…

A

eating, NG tube insertion, promoting lung expansion

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16
Q

head of the bed raised to approximately 30 degrees

A

semi-Fowler’s

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17
Q

Use semi-Fowler’s position for…

A

oral care, gastric feedings

18
Q

entire bed frame tilted with the head of the bed down

A

Trendelenburg’s

19
Q

Use Trendelenberg’s position for…

A

postural drainage, facilitating venous return

20
Q

entire bedframe tilted with foot of the bed down

A

reverse Trendelenberg’s

21
Q

Use reverse Trendelenberg’s position for…

A

promoting gastric emptying, preventing esophageal reflux

22
Q

Maintain bed height at (blank) when the patient is unattended.

A

lowest possible position

23
Q

A (blank) is needed to use side rails as a restraint.

A

healthcare provider order

24
Q

For pressure ulcer risk, a nutritional assessment should be performed within (blank) of admission.

A

24 hours

25
Q

Name 3 signs of nutritional problems.

A
  • loss of 5% of usual weight
  • weight less than 90% of ideal body weight
  • decrease of 10 pounds in brief period
26
Q

Cushion and support (blank) with each position change.

A

bony areas

27
Q

Braden Scale: >18

A

not at risk

28
Q

Braden Scale: 15-18

A

mild risk

29
Q

Braden Scale: 13-14

A

moderate risk

30
Q

Braden Scale: 10-12

A

high risk

31
Q

Braden Scale: <9

A

very high risk

32
Q

Pressure ulcers are most common at…

A

sacrum, heels, greater trochanters

33
Q

The most important risk factors for pressure ulcers are…

A

severity of illness and involuntary weight loss

34
Q

values indicative of malnutrition

A
  • lymphocyte below 1800
  • serum albumin below 3.5
  • body weight loss more than 15%
35
Q

Suspect deep tissue injury with…

A

discolored skin or blood filled blisters

36
Q

Obtain a detailed assessment of pressure ulcers on a (blank) or (blank) basis.

A

weekly, biweekly

37
Q

Alcohol, hydrogen peroxide, Betadine, and certain soaps are (blank) for pressure ulcers.

A

contraindicated

38
Q

Treatment for pressure ulcers should be reevaluated anytime a wound does not show healing during a (blank) interval.

A

2 week

39
Q

Patients should be positioned on their weak/paralyzed side for only…

A

30 minutes

40
Q

If an area of redness develops and does not return to normal within 15 minutes, the…

A

epidermis and dermis are damaged

Fundamentals HESI (3 decks)

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