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HCA 115 unit 4&5 test Questions with 100% Correct Answers
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HCA 115 unit 4&5 test Questions with 100% Correct Answers
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HCA 115 unit 4&5 test Questionswith 100% Correct Answers
What factors does the Braden scale assessment tool take into affect for skin integrity risk -
✔✔1. Sensory perception-Ability to respond meaningfully to pressure related discomfort
2. Moisture-Degree to which skin is exposed to moisture
3. Activity-Decorie of physical activity
4. Mobility-Ability to change and control body position
5. Nutrition-Usual food intake pattern
Friction and sheer
Area is at high risk of developing pressure sores over boney prominences - ✔✔Sacrum
coccyx
Heel of foot
Ischium (sitting bones)
trochanter
elbow
knee
ankle toes and boney areas of foot
back of head
,Who is at risk for developing pressure sores - ✔✔Confined to bed or chair
Moderat to complete dependence for mobility
Loss of bowel or bladder control
Poor nutrition
Altered mental awareness
Problems cents in pain or pressure
Circulatory problems
Older
Obese or very thin
What causes pressure injuries - ✔✔And relieved pressure
Friction
Sharing
Breaking skin
Poor circulation
Moisture
Irritation - stool and urine, so President
Skin on skin contact
Fold areas
Rushing
What can I do to help prevent pressure injuries - ✔✔Skin check - look for redness Bruce's blisters or
open areas each day
Keep moving - move or change position at least every two hours
I deal moisture balance - keep skin clean and a witness against the skin can make it fragile moisturize
dry skin, never grease the crease
Nutrition and hydration Dash eat a well-balanced diet and drink enough fluids
Surface - use your question or mattress and check it daily to ensure that is in good working order
, How to avoid sharing when in bed - ✔✔Who is the person to the right place with bottom in crease
in the bed raise the league at 10 raise the head of the bed
How to relieve skin pressure from the foot - ✔✔Use a footboard for support, use a bed cradle to keep
the blankets off the feet
What is apparent in stage one of pressure sores - ✔✔Skin is red - does not return one pressure
is removed
Area may be painful, firm, warmer or cooler compare to surrounding tissue
What is apparent in stage two of pressure sores - ✔✔The epidermis is gone the skin cracks, blisters
or peels
Area shiny or dry was shallow else or without slough or bruising
What is apparent in stage four pressure sores - ✔✔Muscle and bone are exposed and damaged
Drainage is likely
Especially in feet
Guidelines for prevention and treatment of pressure sores - Misty's 24-3 - ✔✔Number one
always follow care plan
Frequent position changes and repositioning as per care plan
Proper lifting, positioning and transfer text nique's - slider sheet, 30° lateral, pillows for support
Proper diet with lots of fluid
Cleanliness and minimize exposure to moisture and irritants, urine, stool, so
Presido Skin care - verify use of soap or other for your agency Dress and undress
carefully
Dress with long sleeves and long pants - DIPPS
Keep fingernail short and filed - yours and clients
Ensure good lighting
Keep linens clean, dry and wrinkle free
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