Week 13 Prevention Flashcards
When supine what are the areas with the highest pressure
- Occiput
- shoulder blades
- Elbow
- Butt
- Heels
- Toes
When in side lying what are the areas with the highest pressure
- Ear
- shoulder
- Elbow
- Hip
- Thigh
- Heel
- Ankle
When in sitting what are the areas with the highest pressure
- Head
- Shoulders
- Sacrum
- Ischial tuberosities
- Heels
3 Main Points of positioning
- Spread/equalize pressure over a greater area so a bony prominence isn’t taking majority of the weight
- position in such a way that the bony prominences are not in contact with the support surfaces if at all possible
- Change positions regularly a minimum of every 2 hours if laying down if they are in a chair its every 15 minutes
How often should you position someone if they are dependent and need a support system
Every hour
A score of < 18 on the braden scale means
The patient is deemed at risk for pressure ulcers
What is the key to preventing wounds
Mobilization
What are the Diabetic/Neuropathic foot care guidelines
- Inspect feet daily
- Do not walk barefoot
- Do not soak feet
- Moisturize feet but not between toes
- Toenails cut straight across
- Seek medical attention if callus forming
- Control DM/Stop smoking
- Patient education
- Pressure relief for individuals with sensory deficits
How much time does it take for complete relief of pressure to restore oxygen levels
1-2 minutes of complete relief is required to restore oxygen levels to unloaded levels
To try and avoid/prevent Surgical complications what should you do previously with neuropathic/diabetic wounds
- ABI prior to distal extremity surgery
- Revascularization prior to surgery if needed
What factors should you consider when selecting a support surface
- Patient status
- Body structure
- Body weight
- Continence
- Risk for development
- Dependency/mobility
What are the patient needs to consider when selecting a support surface?
- Pressure redistribution
- Shear reduction
- Temperature control
- Moisture control
What is considered break down pressure ? : Basic
32mmHg
The pressure reducing/lower tissue interface pressure is between
23-32mmHg
What is the pressure relieving range
<23mmHg
What is a static surface
Foam/air
Foam/gel
Foam/water
what is a dynamic surface
- moves air through a mattress or has self-adjusting valves that maintains pressure within air cylinders
Pressure Redistribution: Immersion
- depth of penetration into a support surface
Pressure Redistribution: envelopment
- The support surface itself conforms to the body structure
Surface Technology: Gel
- If its cold it retains it and makes it more firm
- doesn’t require a lot of maintenance
Surface Technology: Foam
- Different types
- Can have different layers
- Can be combined with air chambers
Surface Technology: Fluid/air-filled bladders
- Can be filled with air, water, polyvinyl, silicone, different fluids
- Fluids move within the chambers in response to a patients movement
What is the air fluidized feature of a support surface?
- Taking air, gel, or sand and puff it up so that the person laying on it will have moisture wicked away and they are pretty much suspended on air,
- It can puff up in certain areas to provide pressure relief
- Patients with burns, gluteal skin grafts
What is the low-air-loss feature of a support surface?
- Pourus fabric to wick the heat and moisture down into the mattress and then a blower get the heat and moisture out to decrease risk of maceration
- Certain parts of the bed can be set based on the patient
What is alternating pressure feature of a support surface
- Long cylinders of air filled compartments
- These chambers can systematically inflate/deflate in opposite phases so it changes pressure
- Helps patient move side to side
T/F the support surface materials are good ways to replace position changes when medically clear
False
These materials and surfaces do not replace position changes when medically clear
