The skins elasticity

Decreased Turgor=Breakdown

Active organ with functions of;

Secretion

Regulation

Sensation

Temperature

Excretion

Protection

Reduced sensation-pain, tactile and temperature sensation

Immobilization-cant turn and change positions

Nutrition and Hydration deficiencies-limited caloric and protein.

Secretions and Excretions of the skin-Moisture on the skin.(urine, sweat, fecal matter, wound drainage)

External Devices-casts, cloths, restraints, bandages, dressings, tubings.

Vascular Insufficiency-Inadequate arterial blood supply to tissues.

Breakdown-impaired sensory perception, mobility, LOC, shear, friction and moisture.

Braden Scale

(MANS FM)

(Range: 6-23)

Most commonly used assessment for pressure ulcer;

Mobility- Ability to change body position.

Actiity- Degree of physical activity. 

Nutrition-Usual food intake pattern.

Sensory perception-Ability to respond to pressure-related discomfort.

Friction and Shear-

Moisture-

Color;Taut, shiny, darker.

Edema; pitting or swelling.

Lighting; avoid flourescent.

Temperature; use back of your hand.

Assess tolerance for bathing needs.

Activity tolerance, comfort level, cognitive ability, musculoskeletal function and presence of SOB.

 Partial bath- only parts that would cause discomfort (face, hands, axillae and perineal area)

Complete bath- totally dependent client (spinal injury, coma)

Basin or sink with client in a chair.

(Assistance is needed for hard to reach areas.)

Immersion in a tub of water. 

(May still require assistance.)

Continuous stream of water.

(More thorough cleaning than a bed bath but is fatiguing)

Bag contains several soft, nonwoven cotton cloths that are  premoistened in a solution of a no rinse solution. 

(Offers ease of use , reduce bathing time and client comfort)

privacy, maintain safety, maintain warmth, and promote independence.

(Anticipate needs)

5 ways to prevent skin breakdown.

 (WIMPS)

Wound- presence of

Incontinence- Bowel/Urine

Mobility- Limits

Pressure ulcer-Risk assessment (use Braden Scale)

Sensation- Level of 

Physiological needs

 (EW BOSS)

(Maslows hierarchy of needs)

(What motivates people and what they need first)

Elimination

Water

Body temperature

Oxygen

Shelter

Sex

Adopting a new culture

(learning language)

Ethnocentrism

*(TQ)

Holding one's way of life superior to others.

(Their culture is best)

Components of spiritual assessment

(BELIEF)

Belief system

Ethics or values

Lifestyle

Involvement in a spiritual community

Education

Future events

Nursing 

(ADPIE)

The treatment of human responses to health and illness; utilizing the nursing process. 

assessment

diagnosis

planning

implementation

evaluation of patient outcomes

Includes 2 stages that emerge between 4 and 10 years

Heteronomous Morality-(4 and 7) Characterized by belief that rules are unchangeable and that when a rule is broken there is imminent justice. 

Autonomous Morality-child understands that people make the rules and that they can change.

Air 

Water

Food 

Sex