Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide • Monitor the wound for signs of infection: redness, foul odor, edema, or drainage • Monitor vital signs for signs of infection Expected outcomes for pressure ulcers: • Wound demonstrates evidence of healing and granulation tissue with reduction in necrosis • Patient is able tomaintain adequate diet and nutrition for healing and prevention of new ulcers • Patient maintains mobility and ability to keep pressure off high risk areas • Skin remains clean and dry Fall Injuries Falls are the most common cause of injury in adults aged 75 and older. They attribute to the second highest rate of death. This is also the most common cause of death in the elderly population and are more common in women than men. Falls can happen when standing, riding a bicycle, or in work incidents. They can happen related to disease, age, hazards in the area or home, and drug and alcohol use. The injuries come from the weight of the body on a body part due to force. Signs and symptoms of fall injuries: • Contusions • Bruising/hematoma • Fractures to arms, hip, pelvis, wrist, or humerus • Head injury • Subdural hematoma • Lacerations Nursing assessments for fall injuries: • Head to toe general assessment: assess level of consciousness, perform neurological checks, and look for bleeding or fractures • Vital signs; assess for shock (hypotension) • Assess pain levels • Inquire about cause and nature of fall • Inquire about health history and underlying conditions, medication use, and lifestyle factors • Inquire about physical abuse • Review laboratory and radiology reports: x-ray and drug testing Nursing diagnosis for fall injuries: • Pain related to injury • Risk for injury related to disease, age, or hazards • Knowledge deficit related to safety issues and injury prevention

©2018

Achieve

Page 144

of 203