Found Chpt 19

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Found Chpt 19
2011-09-24 16:37:51

Test 2
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  1. Four main functions of skin
    • Protection
    • Excretion/secretion
    • Temperature regulation
    • Sensation
  2. Pressure ulcer risk factors
    • Confinement
    • Inability to move
    • Loss of elimination
    • Poor nutrition
    • Lowered mental awareness
  3. Braden scale 6 points
    • Sensory perception
    • Moisture
    • Activity
    • Mobility
    • Nutrition
    • Friction and shear
  4. Braden scale scores
    • 1-limited
    • 4-fine
    • at risk 15-18
    • Moderate risk 13-14
    • High risk 10-12
    • Severe risk 9
  5. Pressure ulcer staging system
    • I Area of red, deep pink, or mottled skin that does not blanch with fingertip pressure
    • II Partial thickness skin loss involving epidermis/dermis; may look like abraison, blister, or shallow crater. Area may feel warm
    • III Full thickness that may extend to fascia, subq tissue is damager or necrotic; bacterial infection is common and causes drainage; damage to surrounding skin
    • IV Full thickness skin loss with extensive necrosis or damage to muscle, bone; widespread infection; may appear black and dry
    • Unstageable-loss of full thickness; base covered by eschar or contains slough
  6. Four main purposes for bathing
    • Cleanse skin
    • Promote comfort
    • Stimulate circulation
    • Remove waste products secreted through skin
  7. Unconscious patient should be provided mouth care
    at least once every 8 hours; moist swabbing done every 2
  8. A healthy epidermis is important because it
    Acts as a barrier to entry of pathogenic organisms
  9. Elderly patient's skin problems include
    Nails become more brittle and thin and skin is less elastic and more fragile
  10. Patient has an area at left trocanter that is reddened with slightly abraded skin has a
    stage 2 pressure ulcer
  11. Stage III pressure ulcer has
    full thickness skin loss that looks like a deep crater
  12. Partial bath includes
    Face, hands, perineum and axillae
  13. Prevention of pressure ulcers is promoted by
    • Changing position every 2 hours
    • Keeping heels off the bed
    • Using lift devices to move patients