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Aging Skin
| Question | Answer |
|---|---|
| What is the area where the bone sticks out or projects from the body referred to as? | Bony Prominence |
| This occurs when one surface rubs against another | Friction |
| When layer of the skin rub each other. The skin remains in place and under lying tissues move and stretch | Shear |
| An ulcer that develops despite efforts to prevent one through proper use of nursing process | An unavoidable pressure ulcer |
| Pressure ulcers that develop from the improper use of the nursing process | Avoidable pressure ulcer |
| What are examples of bony prominences? | Heels, sacrum, elbows, shoulder blades, back of head, ankle, ears, spinal column |
| What are common causes of Skin breakdown? | Dry skin, fragile and weak capillaries, decreased mobility, decreased sensation to touch, heat and cold, immobility, moisture, poor nail care |
| Describe a Stage One Ulcer | Intact skin with redness over a bony prominence. The redness does not go away when pressure is relieved |
| Describe a Stage Two Ulcer | Partial-thickness skin loss. May be a blister |
| Describe a Stage Three Ulcer | Full thickness tissue loss. |
| Define Slough | Dead tissue that is shed from the skin. |
| Describe a Stage Four Ulcer | Full thickness tissue loss with muscle, tendon and bone exposure |
| Define Eschar | Thick, leathery dead tissue that may be loose or adhered to the skin |
| Describe an Unstageable ulcer | A full thickness tissue loss with the ulcer covered by slough and or eschar. |
| How often should the resident be repositioned? | At least every two hours |
| What nutrient is needed for tissue healing and repair? | Protein |
| List the causes of skin tears | long jagged fingernails, clothing that is too tight, removing adhesive dressings, holding limb too tight, jewelry, buttons, zippers, clothing that is too tight |
| Define Skin tear | A break or rip in the skin |
| Identify Persons at Risk for Skin Tears | Those that need assistance moving, have poor nutrition, have poor hydration, have altered mental awareness, are very thin |
| An open wound increases the residents risk for this | Infection |
| To prevent shearing the head of the bed should not be elevated higher than how many degrees? | 30 |
| How often should a chairfast person be re-positioned? | Every hour |
| Wrinkled linen will not cause pressure | False |
| Pressure Ulcers may occur where skin has contact with skin, what measures can prevent this? | Use of pillows, gauze or pillow cases |
| Other than pressure injuries what is the risk of skin on skin (for example abdominal folds and under breasts) | Fungal/yeast infections |
| What type of equipment will prevent pressure on the tops of legs and feet? | Bed Cradle |
| What type of equipment will prevent pressure on the heels? | Heel protector and/or heel elevator |
| What type of device will relieve pressure when a resident is sitting in a wheelchair? | Gel or fluid filled cushions |
| What type of device will help to relieve pressure for an individual that is on bedrest? | An alternating air pressure mattress overlay. Pressure relieving mattresses/beds |
| This piece of equipment helps to decrease foot drop | A foot board |
| If you observe red skin over pressure points you should massage the area with moisturizing lotion. | False, massaging the area may increase the damage to skin tissues |
| This document is often used in healtcare to identify the residents at risk for skin breakdown | Braden Scale |
| An individual that is not repostioned may develop a pressure ulcer with in 8 hour | False, a pressure ulcer may develop in 2-6 hours |
| This type of equipment will help to decrease skin tears | Skin protectors/sleeves |
| The skin should be observed no more than weekly for areas of pressure | False, the skin should be inspected at least daily. It is best to observe each time that the resident is assisted with care (ADL's) |
| The older person should wear sweaters and/or be protected from drafts since they tend to be more sesnitive to cold | True, this is because of the loss of fatty tissue layer |
| What actions should the CNA take to decrease dry skin? | Avoid hot water, bath no more than twice a week, use lotion. moisturizing soaps as directed. |
| Why is the elder patient at risk for burns? | The skin has fewer nerve endings. This decreases the ability to sense heat, cold, pressure and pain. |
| The older person is at greater risk for skin disorders | True |
| Purulent | drainage that indicates infection. May be yellow , brown, or green. pus |
| Sanguinous | Bloody drainage |
| Serosanguineous | water drainage that contains blood |
| Serous | watery drainage, usually clear. Fluid that fills a blister |
Created by:
dkayes
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