Aging Skin
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| What is the area where the bone sticks out or projects from the body referred to as? | Bony Prominence
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| This occurs when one surface rubs against another | Friction
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| When layer of the skin rub each other. The skin remains in place and under lying tissues move and stretch | Shear
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| An ulcer that develops despite efforts to prevent one through proper use of nursing process | An unavoidable pressure ulcer
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| Pressure ulcers that develop from the improper use of the nursing process | Avoidable pressure ulcer
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| What are examples of bony prominences? | Heels, sacrum, elbows, shoulder blades, back of head, ankle, ears, spinal column
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| 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
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| Describe a Stage One Ulcer | Intact skin with redness over a bony prominence. The redness does not go away when pressure is relieved
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| Describe a Stage Two Ulcer | Partial-thickness skin loss. May be a blister
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| Describe a Stage Three Ulcer | Full thickness tissue loss.
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| Define Slough | Dead tissue that is shed from the skin.
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| Describe a Stage Four Ulcer | Full thickness tissue loss with muscle, tendon and bone exposure
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| Define Eschar | Thick, leathery dead tissue that may be loose or adhered to the skin
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| Describe an Unstageable ulcer | A full thickness tissue loss with the ulcer covered by slough and or eschar.
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| How often should the resident be repositioned? | At least every two hours
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| What nutrient is needed for tissue healing and repair? | Protein
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| 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
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| Define Skin tear | A break or rip in the skin
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| 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
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| An open wound increases the residents risk for this | Infection
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| To prevent shearing the head of the bed should not be elevated higher than how many degrees? | 30
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| How often should a chairfast person be re-positioned? | Every hour
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| Wrinkled linen will not cause pressure | False
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| Pressure Ulcers may occur where skin has contact with skin, what measures can prevent this? | Use of pillows, gauze or pillow cases
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| Other than pressure injuries what is the risk of skin on skin (for example abdominal folds and under breasts) | Fungal/yeast infections
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| What type of equipment will prevent pressure on the tops of legs and feet? | Bed Cradle
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| What type of equipment will prevent pressure on the heels? | Heel protector and/or heel elevator
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| What type of device will relieve pressure when a resident is sitting in a wheelchair? | Gel or fluid filled cushions
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| 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
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| This piece of equipment helps to decrease foot drop | A foot board
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| 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
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| This document is often used in healtcare to identify the residents at risk for skin breakdown | Braden Scale
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| 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
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| This type of equipment will help to decrease skin tears | Skin protectors/sleeves
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| 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)
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| 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
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| 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.
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| 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.
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| The older person is at greater risk for skin disorders | True
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| Purulent | drainage that indicates infection. May be yellow , brown, or green. pus
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| Sanguinous | Bloody drainage
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| Serosanguineous | water drainage that contains blood
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| Serous | watery drainage, usually clear. Fluid that fills a blister
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Created by:
dkayes
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