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Skin Tear - Correct Answer-a break or rip in the outer layers of the skin; the epidermis separates from the underlying tissues Stage 1 pressure ulcer - Correct Answer-intact skin with nonblanchable redness (does not turn white when pressured is applied) stage 2 pressure ulcer - Correct Answer-Skin no longer intact, fleshy pink base with a break in skin integrity This is where Blistering is stage 3 pressure ulcer - Correct Answer-Yellow fatty tissue seen at the base stage 4 pressure ulcer - Correct Answer-Bright Red Muscle or Bone is seen clear liquid diet - Correct Answer-a diet that consists of foods that are liquid at room temperature and leave little residue in the intestine. Ex: Water, Sprite, Ginger Ale, all beverages without any residue, broth, Jello Full Liquid Diet - Correct Answer-Foods liquid at room temp or melt at body temperature; Foods on clear liquid diet PLUS custard, eggnog, strained
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Skin Tear - Correct Answer-A break or rip in the outer layers of the skin Prevention of Skin Tears - Correct Answer--Move, turn, position, or transfer the person -prevent shearing and friction by using turn pads, sheets, pillows -keep yours and the residents nails short and smoothly filed -Do not wear rings with raised stones -Be patient -Dress and undress resident carefully and in soft clothes -Apply arm and leg protectors as ordered -Provide good lighting -Provide safe area for wandering -Remove tape carefully -Do not apply adhesive tape Characteristics of Aging skin - Correct Answer--skin becomes less elastic -skin loses strength -brown spots appear -fewer nerve endings and blood vessels -fatty tissues layer is lost -skin thins and sags -skin is fragile and easily injured -increased sensitivity to heat and cold Makes it harder for the elderly to heal quickly Pressure Ulcer Stages - Correct Answer-Stage 1: intact skin with redness over bony prominence Stage 2: Partial-thickness skin loss Stage 3: Full-thickness tissue loss Stage 4: Full-thickness tissue loss with muscle, tendon, and bone exposure Prevention of pressure ulcers - Correct Answer-Good nursing crae, cleanliness, and skin care -Manage mositure, good nutrition, and fluid balance, and relieving pressure How often should a resident change positions - Correct Answer-every 2 hours (q2)
How are pressure areas treated - Correct Answer-Wound care productd, drugs, treatments, and equipment Protective devices such as bed cradle, heel and elbow protectors, heel and foot elevators, gel-or fluid- filled pads and cushions, special beds are used to help heal Review: bathing and all personal hygiene skills: Oral care, dressing, hair care, shaving, nail care, foot care, bed making - Correct Answer-When dressing dress weak side undress strong side first NEVER cut nails Common skin and hair conditions for a resident - Correct Answer-Hair loss (Alopecia), dandruff, lice, scabies, Hirsutism (excessive boy hair) Nutrition - Correct Answer-The processes involved in the ingestion, digestion, absorption, and use of foods and fluids by the body How does a poor diet affect the LTCF resident? - Correct Answer-A poor diet can compromise the health of an LTCF resident. Poor hydration and nutrition can mess up the digestive system, skin, happiness. Going off your diet can compromise your health by creating a choking hazard, or risk of edema/swelling. What factors may affect the nutrition of an older person? - Correct Answer-culture, religion, appetite, illnss, drugs, chewing problems, swallowing problems, disability, impaired cognitive function What food/nutrients help wounds heal - Correct Answer-Protein (Meat, fish, poultry, eggs, milk, milk products, cereals, beans, peas, and nuts MyPlate - Correct Answer-Encourages well-balanced meals with foods from 5 food groups (Grains, Vegetables, Fruits, Dairy, Protein) feeding precautions - Correct Answer--Use teaspoons to feed resident -Teaspoon is 1/3 full to swallow and chew easily -Rotate between food and fluids Use numbers on a clock for a visually impaired person -place food on strong side of person -Check food temperature -Do not rush resident dysphagia - Correct Answer-difficulty swallowing Care for resident with Dysphagia - Correct Answer-Thickened liquid-No Lumps Medium Thick- Nectar like Extra Thick- Thick like honey
Yogurt like- Thick like pudding or yogurt Puree- No lumps, mound on a plate -Know signs and symptoms -feed according to plan -follow aspiration precautions -report changes in how resident eats -observe for signs and symptoms of aspiration What is meant by swallowing precautions - Correct Answer-Taking preautions in food that is given to residents for example avoid foods that need chewing, food that is a certain txture or temperature -watch to see if the patient has difficulty swallowing foods What is the difference between a clear liquid and a full liquid diet - Correct Answer- DAIRY ML=OZ - Correct Answer-30mL=1oz intake - Correct Answer-the amount of fluid/food taken in output - Correct Answer-urine, vomitus, diarrhea, and wound drainage Diabetes - Correct Answer-A condition in which the body is unable to produce enough insulin, the hormone required for the metabolism of sugar How to care for a diabetic resident - Correct Answer--Treated with insulin, drugs, diet, and exercise Consistency is key!! Same amount of carbohydrates, proteinm and fat are eaten each day Eating meals and snacks at same time each day Report what the person did and did not eat Symptoms of Diabetes - Correct Answer--Being very thirsty -Frequent Urination -Feeling very hungry or tired -weight loss without trying -sores that heal slowly -dry, itchy skin -tingling or loss of feeling in the feet
-blurred vision Hypoglycemia - Correct Answer-abnormally low level of sugar in the blood -fatigue, weakness, dizziness, faintness, vision changes -tingling around mouth -headache -skin becomes cold and clammy; sweating -respirations become rapid and shallow -pulse becmes rapid -blood pressure low hyperglycemia - Correct Answer-excessive sugar in the blood -weakness -drowsiness -vision blurred -Dry mouth -skin becomes dry -face becomes flushed -respirations become rapid, deep, and labored -Pulse becomes rapid and weak -Blood pressure is low -Frequent urination -leg cramps gastronomy tube - Correct Answer-The surgical placement of a feeding tube from the exterior of the body directly into the stomach. jejunstomy tube - Correct Answer-A feeding tube is inserted into a surgically created opening in the small intestine