NUR 242 Med/Surg Exam 1
Hyperbaric - oxygen therapy (HBOT) - ✔️✔️administration of oxygen under high
pressure, raising tissue oxygen concentration. Usually received under limb life-
threatening wounds such as - burns, necrotizing infections, brown recluse spider bites,
osteomyelitis, and diabetic ulcers
patient at risk for pressure injury - cardiovascular status - ✔️✔️- presence or absence
of peripheral edema
-hand-vein filling in the dependent position
-neck-vein filling in the recumbent and sitting position
- weight gain or loss
patient at risk for pressure injury - cognition and mental status - ✔️✔️-level of
consciousness
- orientation to time, place and person
- can the patient read a seven word sentence containing three syllables or fewer
patient at risk for pressure injury - condition of skin - ✔️✔️- assess skin cleanliness
- observe all skin areas, especially bony prominences and areas in contact with the bed
or other firm surfaces
- measure and record any redness or loss of integrity
- photograph areas of concern
- note presence of skin tenting over sternum and forehead
- note moistness of skin and mucous membranes
Patient at risk for pressure injury - with wounds - ✔️✔️- remove dressing (noting
condition of dressing)
- cleanse wound and remove and compare with previous notations of wound condition
- presence, amount and nature of exudate
- use disposable paper tape measurement to measure wound diameter and depth
- amount (%) and type of necrotic tissue
- presence of granulation/epithelium
- presence or absence of cellulitis
presence or absence of odor
take patients temperature to assess for fever
Patient at risk for pressure injury - understanding of illness and compliance with
treatment - ✔️✔️-s/s to report to primary care doctor
-drug therapy plan (correct time and dosing)
- ambulation or positioning schedule
- dressing changes/skin care
- nutrition modifications (24-hr diet recall)
, GFTT ( Geriatric Failure To Thrive) Complex Syndrome - ✔️✔️Under nutrition
Impaired mobility
Depression
Cognitive impairment
Depression older adults - ✔️✔️Most common mental health/behavioral health problem
among older adults.
Use Geriatric Depression Scale form
Mood disorder having cognitive, affective, physical manifestations
Primary (lack of neurotransmitters)
Secondary or situational
Dementia older adults - ✔️✔️slowly progresses
generally chronic
intellectual impairment
Most common Alzheimer's
Multi-infarct dementia, the second most common resulting from a vascular disorder
Delirium older adults - ✔️✔️Acute and fluctuating onset
results from an unfamiliar place
Symptoms - inattentiveness, disorganized thinking, and altered level of consciousness
Nurse's role in Rehab - ✔️✔️Advocate for the patient and family
Create therapeutic rehab milieu
provide whole person patient-centered care
Collaborate with healthcare team for patient outcome and develop care plan
Communicate with effectively with all members of the health care team, patient and
family
Evaluate effectiveness of plan of care for the patient and family
Use Braden scale - skin break down risk
Safe Patient Handing and Mobility (SPHM) - ✔️✔️-Maintain a wide, stable base with
your feet
-Put the bed at the correct height - waist level while providing direct care and hip level
when moving patients
- Keep the patient or work directly in front of you to prevent your spine from rotating
- Keep the patient as close to your body as possible to prevent reaching
walker - assisted and cane - assisted procedure - ✔️✔️- Apply a transfer belt around
patients waist
- guide patient to a standing position
- remind patient to place both hands on the walker
- ensure that the patient's body is well balanced
Hyperbaric - oxygen therapy (HBOT) - ✔️✔️administration of oxygen under high
pressure, raising tissue oxygen concentration. Usually received under limb life-
threatening wounds such as - burns, necrotizing infections, brown recluse spider bites,
osteomyelitis, and diabetic ulcers
patient at risk for pressure injury - cardiovascular status - ✔️✔️- presence or absence
of peripheral edema
-hand-vein filling in the dependent position
-neck-vein filling in the recumbent and sitting position
- weight gain or loss
patient at risk for pressure injury - cognition and mental status - ✔️✔️-level of
consciousness
- orientation to time, place and person
- can the patient read a seven word sentence containing three syllables or fewer
patient at risk for pressure injury - condition of skin - ✔️✔️- assess skin cleanliness
- observe all skin areas, especially bony prominences and areas in contact with the bed
or other firm surfaces
- measure and record any redness or loss of integrity
- photograph areas of concern
- note presence of skin tenting over sternum and forehead
- note moistness of skin and mucous membranes
Patient at risk for pressure injury - with wounds - ✔️✔️- remove dressing (noting
condition of dressing)
- cleanse wound and remove and compare with previous notations of wound condition
- presence, amount and nature of exudate
- use disposable paper tape measurement to measure wound diameter and depth
- amount (%) and type of necrotic tissue
- presence of granulation/epithelium
- presence or absence of cellulitis
presence or absence of odor
take patients temperature to assess for fever
Patient at risk for pressure injury - understanding of illness and compliance with
treatment - ✔️✔️-s/s to report to primary care doctor
-drug therapy plan (correct time and dosing)
- ambulation or positioning schedule
- dressing changes/skin care
- nutrition modifications (24-hr diet recall)
, GFTT ( Geriatric Failure To Thrive) Complex Syndrome - ✔️✔️Under nutrition
Impaired mobility
Depression
Cognitive impairment
Depression older adults - ✔️✔️Most common mental health/behavioral health problem
among older adults.
Use Geriatric Depression Scale form
Mood disorder having cognitive, affective, physical manifestations
Primary (lack of neurotransmitters)
Secondary or situational
Dementia older adults - ✔️✔️slowly progresses
generally chronic
intellectual impairment
Most common Alzheimer's
Multi-infarct dementia, the second most common resulting from a vascular disorder
Delirium older adults - ✔️✔️Acute and fluctuating onset
results from an unfamiliar place
Symptoms - inattentiveness, disorganized thinking, and altered level of consciousness
Nurse's role in Rehab - ✔️✔️Advocate for the patient and family
Create therapeutic rehab milieu
provide whole person patient-centered care
Collaborate with healthcare team for patient outcome and develop care plan
Communicate with effectively with all members of the health care team, patient and
family
Evaluate effectiveness of plan of care for the patient and family
Use Braden scale - skin break down risk
Safe Patient Handing and Mobility (SPHM) - ✔️✔️-Maintain a wide, stable base with
your feet
-Put the bed at the correct height - waist level while providing direct care and hip level
when moving patients
- Keep the patient or work directly in front of you to prevent your spine from rotating
- Keep the patient as close to your body as possible to prevent reaching
walker - assisted and cane - assisted procedure - ✔️✔️- Apply a transfer belt around
patients waist
- guide patient to a standing position
- remind patient to place both hands on the walker
- ensure that the patient's body is well balanced
