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Aging Skin

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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