“Self-care by which people attend to such functions as bathing, toileting, general body hygiene and grooming”
Personal Hygiene
The epidermis and dermis
layers of the skin
occipitus, ears, elbows, hip, sacrum, heels
Pressure area/points
Sensory Perception, Moisture, Activity, Mobility, Nutrition
Risk assessment Categories
this should be carried out with all clients at admission, and daily thereafter for those identified at risk for skin breakdown
A head-to-toe skin assessment
removes accumulated oil ,dead skin and perspiration
Bathing
A pigment that protects the cells from ultraviolet radiation
Melanin
Follow this guideline if a patient develops or is admitted with pressure ulcer
Assessment and Management of Pressure Injuries for the Inter-professional Team
This is used to score the patients
Descriptor
A basic strategy to prevent pressure ulcer
2 hourly repositioning
the second most frequent healthcare acquired infection (HAI)
Ventilator-associated pneumonia
A protein that hardens and waterproof the skin
Keratin
These clients can develop pressure ulcer within the first week of hospitalization
Elderly clients
Total score 15-18
Mild risk
A special type of mattress to reduce pressure
Egg crate mattress
Ventilator Associated Pneumonia is reduced by up to 42% when this is done
Oral care for the patients
A layer of the epidermis that differentiate "thick skin" from "thin skin"
Stratum lucidum
These patients are 37.5 times more likely to develop pressure ulcers.
Patients with fecal incontinence and impaired mobility
Total score </= 9
severe risk
The most sensitive marker (blood test) to assess patient's nutritional status
This can interfere with sebum ,causing skin dryness
Excessive Bathing
The two layers of the Dermis
The papillary and reticular layer
Partial thickness skin loss involving epidermis, dermis, or both
Stage II pressure ulcer
The highest mark received for each category
4
The doctor orders an x-ray of the wound to rule out
Bone infection and osteomyelitis