Skin Integrity Flashcards
As surface area increases, (blank) increases.
friction
Name 3 ways to decrease friction.
- tell the patient to bend knees and lift hips
- lift the patient rather than push
- use a drawsheet or transfer board
localized injury to the skin and/or underlying tissue, usually over a bony prominence
pressure ulcer
most widely used scale for pressure ulcer risk
Braden Scale
six subscales of Braden Scale
sensory perception, moisture, activity, mobility, nutrition, friction/shear
(Braden Scale) The lower the total score, the (blank) the risk of pressure ulcers.
higher
Hospitals do not get reimbursement for…
Stage III and IV pressure ulcers
Red, blue, mottled skin means…
impaired circulation
Change position every (blank) hours.
2
If the patient is totally immobile, keep the (blank) off the bed.
heels
If the patient is in a chair, they should be repositioned…
every hour
If the patient is in a chair, encourage self weight shifting every…
15 minutes
Do not massage (blank) and (blank).
red skin, bony prominences
head of the bed raised to 45 degrees or more
Fowler’s
Use Fowler’s position for…
eating, NG tube insertion, promoting lung expansion
head of the bed raised to approximately 30 degrees
semi-Fowler’s
Use semi-Fowler’s position for…
oral care, gastric feedings
entire bed frame tilted with the head of the bed down
Trendelenburg’s
Use Trendelenberg’s position for…
postural drainage, facilitating venous return
entire bedframe tilted with foot of the bed down
reverse Trendelenberg’s
Use reverse Trendelenberg’s position for…
promoting gastric emptying, preventing esophageal reflux
Maintain bed height at (blank) when the patient is unattended.
lowest possible position
A (blank) is needed to use side rails as a restraint.
healthcare provider order
For pressure ulcer risk, a nutritional assessment should be performed within (blank) of admission.
24 hours
Name 3 signs of nutritional problems.
- loss of 5% of usual weight
- weight less than 90% of ideal body weight
- decrease of 10 pounds in brief period
Cushion and support (blank) with each position change.
bony areas
Braden Scale: >18
not at risk
Braden Scale: 15-18
mild risk
Braden Scale: 13-14
moderate risk
Braden Scale: 10-12
high risk
Braden Scale: <9
very high risk
Pressure ulcers are most common at…
sacrum, heels, greater trochanters
The most important risk factors for pressure ulcers are…
severity of illness and involuntary weight loss
values indicative of malnutrition
- lymphocyte below 1800
- serum albumin below 3.5
- body weight loss more than 15%
Suspect deep tissue injury with…
discolored skin or blood filled blisters
Obtain a detailed assessment of pressure ulcers on a (blank) or (blank) basis.
weekly, biweekly
Alcohol, hydrogen peroxide, Betadine, and certain soaps are (blank) for pressure ulcers.
contraindicated
Treatment for pressure ulcers should be reevaluated anytime a wound does not show healing during a (blank) interval.
2 week
Patients should be positioned on their weak/paralyzed side for only…
30 minutes
If an area of redness develops and does not return to normal within 15 minutes, the…
epidermis and dermis are damaged
