Integumentary System
This is the largest organ of the body.
What is the skin?
This is the most essential nutrient for life.
What is water?
This is the minimum frequency a patient should be repositioned to help prevent pressure injuries.
What is every 2 hours (Q2 hours)?
During perineal care, cleansing should always be done in this direction.
What is from front to back (cleanest to dirtiest)?
This sense usually remains intact until the time of death, even in a comatose patient.
What is hearing?
A pressure injury is most commonly found over these areas of the body.
What are bony prominences?
When assisting a patient who has weakness on one side after a stroke, you should feed the patient from this side of the mouth.
What is the unaffected (good) side?
HAPI stands for this .... and at what point during the patient's hospital admission is it considered at HAPI?
What is a Hospital-Acquired Pressure Injury and 24 hours.
When dressing a patient with weakness or paralysis on one side, which side is dressed first and which side is undressed first?
What is dress the weak or affected side first, and undress the strong (unaffected) side first so the weak side is removed last?
When providing care for a dying patient, frequent care of these tissues helps prevent dryness and discomfort.
What are the mucous membranes (mouth, eyes, and nose)?
Name 2 functions of the skin
Defense against infection, protects underlying muscles/bones/organs from injury, regulates body temperature, allows body to feel different sensations (pressure, pain, touch, temperature), eliminates waste & lubricates skin.
Name 3 of the 6 essential nutrients our body needs for optimal health.
What are protein, carbs, fat, vitamins, minerals & water.
Name three medical devices that can contribute to pressure injuries if not monitored properly.
What are oxygen tubing/masks, CPAP/BiPAP masks, pulse oximeters, ET tubes, NG tube, feeding tubes, sequential compression devices (SCDs), braces, or splints?
These are the four times oral hygiene should routinely be provided
What are before breakfast, after meals, at bedtime, and as needed (minimum once daily)?
Name three comfort measures that can improve the quality of life for a dying patient.
What are a back massage, soft music, reading to the patient, maintaining a comfortable room temperature, using air fresheners, proper positioning, or diet as tolerated?
Name 3 pressure points on the patient's body that are at risk for pressure injuries.
What are heels, sacrum/coccyx, shoulder, elbows, knees, hips, ears.
Name 3 examples of food on a full liquid diet.
What are anything on clear liquid diet plus: fruit/vegetable juices, milk, ice cream, sherbert, pudding, yogurt - no fruit, cream soups, cooked cereals, mashed potatoes.
Name 3 factors that put patients at risk for pressure injury.
Different disease processes (PVD, anemia, infection, CA), edema, sensory impairment, stroke/paralysis, smoker, malnutrition, immobility, medical devices, moisture on skin.
Name four daily hygiene needs discussed in the presentation.
What are bathing, skin care, back care, oral hygiene, shaving, hair care, nail care, or perineal care?
Name four physical signs that death may be approaching.
What are cold and mottled hands and feet, weak/irregular pulse, decreased blood pressure, changes in respirations (Cheyne-Stokes, apnea, dyspnea), loss of consciousness, confusion/agitation, urinary or fecal incontinence, fixed or glassy gaze, increased secretions, or jaw relaxation?
Name four risk factors that increase a patient's chance of skin breakdown.
What are immobility, incontinence, excess perspiration, dryness, wound drainage, paralysis/paresthesia, poor nutrition, confusion/agitation, decreased level of consciousness, or decreased circulation?
When assisting a patient with their meal, name 4 things the PCA should do.
Encourage/allow patient to do as much as possible; use a spook half full, do not rush, if patient has poor vision-name foods as you offer them or describe position of foods on tray, watch for signs of choking/coughing, alternate between liquids & solids, allow food to cool, wash hands/face before & after meal, document intake.
List 4 interventions included in the PCA's role to prevent HAPIs.
What are : reposition every 2 hours, float the heels, keep skin clean and dry, use barrier cream, inspect skin frequently, offload bony prominences with pillows or wedges, avoid friction and shear, encourage nutrition and hydration, keep sheets smooth and dry, or assist with mobility?
When providing daily hygiene to a patient, name 4 observations that should be reported to the nurse.
Skin dryness/rash/redness/swelling, numbness/tingling/pain, bruising/blisters/other sores, ingrown toenail, foul odors, bleeding, loose/broken teeth/dentures, coated tongue
When a patient has passed away, name 4 things the PCA may do or assist with.
What are: take a set of vitals, note time, cleanse skin of any mucus/urine/feces/other fluids, place body in proper alignment, remove tubes/drains, change linens as needed, dress patient in a clean gown, straighten up the room, provide privacy for family/friends, gather patient belongings to send with family/funeral home.