Show:
Chapter 4, 6, & 7
Chapter 19
Chapter 19
100

Name the steps in the Nursing Process.

Assessment

Data Analysis/Problem Identification

Planning

Implementation

Evaluation

100

What are the functions of the skin?

  • Protection
  • Sensation
  • Temperature regulation
  • Excretion
  • Secretion
100

What is proper nutrition to prevent skin breakdown?

Increased protein

Adequate hydration


200

What is a SMART goal?

Specific

Measureable

Achievable

Relevant

Time Frame

200

What happens to skin as it ages?

  • Loss of elastic fibers 
  • Skin becomes thinner, fragile, slower to heal
  • Decreased sebaceous activity 
  • Temperature control is altered
  • Hair becomes thinner, grows slower
200

How often do we move a patient in bed?

Turn/reposition the patient every 2 hours while in bed.

300

What is objective data?

Data the nurse obtains through their assessment and observation

300

What are risk factors for pressure injuries?

  • Immobility
  • Incontinence
  • Diaphoresis
  • Inadequate nutrition
  • Lowered mental awareness
  • Excessive diaphoresis
  • Extreme age
  • Edema
300

In this stage of injury, the skin is intact, but the tissue beneath the surface is damaged and appears purple or dark red.

Deep tissue injury

400

What are the purposes of documentation?

  • Provides a written record of the history, treatment, care, and response of the patient while under the care of a health care provider
  • Is a guide for reimbursement of costs of care
  • Shows the use of the nursing process
  • Provides data for quality assurance studies
  • Is a legal record that can be used as evidence of events that occurred or treatments given - may be used in a court of law
  • Shows progress toward expected outcomes
400

Full thickness skin loss with damage to or necrosis of subQ tissue but no bone, muscle, or tendons exposed is what stage of pressure injury?

Stage 3

400

In this stage, the skin is not intact, and there is a partial thickness skin loss with no fatty tissue visible.

Stage 2

500

What part of the nursing process is the nurse participating in when they are passing medications?

Implementation

500

What does the Braden Scale measure?

Sensory perception

Moisture

Mobility

Nutrition

Friction & shear

500

What should the nurse do if they find a reddened area on a patient's back?

Press it to see if it is blanchable