layers of the skin - ✔️✔️dermis and epidermis
stages - ✔️✔️1- intact skin, does not blanch
2- partial thickness loss with exposed dermis
3-full thickness loss into fascia
4 - full thickness with extensive necrosis to muscle, bone, supporting structure
protective devices/restraints - ✔️✔️valid reasons
positioning - ✔️✔️-fowlers
-semi-fowlers
-supine
-side lying
-knee chest
communication - ✔️✔️open ended- seeking more information from client
close ended- yes or no
different languages- medical/hospital approved interpreter
non judgmental
verbal
non verbal
reflection
most common work related injury to health care workers? - ✔️✔️back
vesicular (lung sounds) - ✔️✔️over the periphery of the lung fields
bronchovesicular (lung sounds) - ✔️✔️heard over central chest
bradypnea (lung sounds) - ✔️✔️slow breathing
trachypnea (lung sounds) - ✔️✔️fast breathing
apical (heart sounds) - ✔️✔️left, mid-clavicular, 5th intercostal
Bradycardia (heart sounds) - ✔️✔️slow heart rate less than 60