Editing Fundamentals of Nursing – RN Flashcards (section)

== Mobility and skin integrity ==

;What are the major systemic hazards of immobility?
:Muscle atrophy, contractures, and foot drop; orthostatic hypotension and venous thromboembolism; atelectasis and hypostatic pneumonia; pressure injury; constipation and impaction; urinary stasis, calculi, and infection; and depression and disorientation.

;How often should patients be repositioned, and what head of bed angle limits shear?
:At least every two hours in bed and at least every hour in a chair, with chair bound patients taught to shift weight every 15 minutes. Keep the head of the bed at or below 30 degrees when possible, because higher angles increase sacral shear. Meals and enteral feeding are exceptions and require at least 30 degrees.

;What does the Braden Scale measure, and what score indicates risk?
:Six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Lower total scores mean higher risk, and a score of 18 or less generally indicates risk in adults.

;How are pressure injuries staged?
:Stage 1 is intact skin with nonblanchable erythema. Stage 2 is partial thickness dermal loss, a shallow open ulcer or a serum filled blister. Stage 3 is full thickness with visible fat but no exposed bone, tendon, or muscle. Stage 4 is full thickness with exposed bone, tendon, or muscle. Unstageable means the base is obscured by slough or eschar. A deep tissue pressure injury is persistent nonblanchable deep red, maroon, or purple discoloration or a blood filled blister.

;Which two commonly suggested measures are actually contraindicated in pressure injury prevention?
:Massaging reddened bony prominences, which worsens already damaged tissue, and donut or ring cushions, which concentrate pressure at the rim and impair circulation.