It is the bodys first line of defense against the environment and microorganisms. It is the largest organ of the body.
100
How often are at risk residents skin inspected for skin breakdown and documented by a licensed nurse?
Completed daily with personal cares. Documented weekly by licensed nurse or with a change in condition
100
A barrier cream should be applied at the first sign of stool or urine incontinence, True or False?
True
100
What is friction?
Skin rubbing over a surface like sheets
100
How often should a patient be repositioned while in bed? Up in the chair/wheelchair?
Every 2 hours while in bed
Every one hour while in up in wheelchair or chair
200
What is the greatest risk factor in the development of a pressure ulcer?
Immobility
200
Poor nutrition can delay wound healing and put a patient at risk for the development of a pressure ulcer. True or False
True
200
What is the ingredient in a barrier cream that provides a high level of skin protection from incontinence?
Zinc Oxide
200
What can be applied to a patients bed to decrease skin breakdown due to FRICTION?
A draw sheet or lift sheet and the use of 2 staff members to boost a patient in bed
200
What is utilized on a patients chair or wheelchair to reduce pressure?
A air or gel cushion
300
What is the first sign of a pressure ulcer?
Persistent redness or discoloration that does not disappear when pressure is relieved.
300
Where do pressure ulcers most likely occur?
Bony prominences, such as the back of the head, ears, shoulders,spine, hips, coccyx, sacrum, ankles and heels. Also may occur under compression stockings, casts, oxygen tubing or braces.
300
Name 2 ways you can protect a residents skin from moisture?
Use a pillow case in folds to absorb moisture and prevent friction to area
Apply barrier creams
Frequent changes of adult briefs
300
What can be done to decrease shearing to the skin when the patient is in bed?
Keep the head of the bed lower than 30 degrees.
300
What are methods to decrease pressure to heels?
Pillows
Heel suspension boots
400
Name 3 abnormal findings to report to the RN when inspecting the patients skin
Change in skin color, open areas or abrasions, bruising, mushy or boggy area or a painful area when touched
400
What are 5 factors that contribute to pressure ulcer formation?
Moisture,Friction, shear, immobility and poor nutrition
400
What are some methods to improve a patients nutritional status?
Offer frequent sips of nutritional supplements and fluids throughout the day
Offer foods high in protein first
Assist with feeding if needed
400
What are 3 ways to prevent pressure ulcers?
Repositioning
Applying a barrier cream
Avoid friction and shear
Elevating heels
Pressure relieving devices
400
What are methods to pad between bony prominences such as contracted extremities?
Use of rolled towels, rolled blanket or small pillows
500
What is shearing?
When the skin sticks to a surface while the body is being pulled
500
What are factors that lead to skin breakdown in the ELDERLY resident?
Thinning skin, decrease moisture to skin, decrease elasticity to skin, decreased fat layers.
500
What are 3 sources of moisture that can damage the skin?
Incontinence of urine and stool
Perspiration
Wound drainage
500
True or False: Applying sheep skin, massaging bony prominences, applying heating pads and use of donut rings can decrease skin damage
False
500
How do you check to make sure the patients cushion on their chair or bed is decreasing pressure to the buttock area?
Evaluate by placing your hand under chair cushion or mattress overlay.
Lifting your fingers up under the patient's hips, buttocks or shoulders
You should feel at least one inch of padding between resident and your fingers.