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
