NUR 242 Med/Surg Exam 1
Adaptive equipment - ✅✅ -buttonhook
extended shoehorn
plate guard and spork
gel pad
foam buildups
hook and loop fasteners
long-handled reacher
elastic shoelaces or velcro shoe closure
Airborne Precautions - ✅✅ -private room with negative pressure
airflow, keep door closed, N95 respirator, patient to wear surgical mask
when leaving room a clinical reason
M - measles
T - tuberculosis
V - varicella (including disseminated zoster)
cane teaching - ✅✅ -- be sure cane is at the height of the patients wrist
when the arm is placed at his or her side
- remind patient to place his or her strong hand on cane
- ensure that the patient's body is well balanced
- move the cane and weaker leg forward at the same time
- move the stronger leg one step forward
- check balance and repeat the sequence
Care of Patient in Sickle Call Crisis -✅✅ -Give prescribed pain
medication
hydrate with normal saline IV, encourage oral intake of fluids without
caffeine
administer oxygen
remove restrictive clothing, no blood pressure with external cuff
check circulation in extremities every hour
✅✅
Cellulitis - -generalized infection with either staphylococcus or
streptococcus and involves deeper connection tissue
infection can spread by scratching or rubbing the skin
,can result from a secondary bacterial infection of an open wound or
unrelated to skin trauma
localized area of inflammation that may enlarge rapidly if not treated
warm compresses to the area are recommended
treatment with IVABT
Central Line Access Devices - ✅✅ -All central line access devices
terminate in the superior vena cava (PICC line, implantable ports,
tunneled and non-tunneled catheters, and central lines)
insertion requires informed consent
need to have a chest x-ray prior to use
Changes in Dark skin - Bleeding - ✅✅ -- Compare the affected area
with the same area on the unaffected body side for swelling or skin
darkening
- if the patient has thrombocytopenia, petechiae may be present on the
oral mucosa or conjunctiva
Changes in Dark skin - cyanosis - ✅✅ -- examine lips and tongue for
gray color
- examine nail beds, palms, and soles for blue tinge
- Examine conjunctiva for pallor
Changes in Dark skin - Inflammation - ✅✅ -- Compare effective area
with non affected area for increased warmth
-examine skin of affected area to determine whether it is shiny or taut or
pits with pressure
- Compare the skin color of affected area with the same area on the
opposite side of the body
- palpate the affected area and compare it with unaffected area to
determine whether texture is different (affected area may feel hard or
"woody"
Changes in Dark skin - Jaundice - ✅✅ -- Check for yellow tinge to oral
mucous membranes, especially the hard palate
- examine the sclera nearest to the iris rather than the corners of the eye
, Chapter 24 - skin layers - ✅✅-- Epidermis
- dermis
- subcutaneous - hypodermis
Common health Issues and Concerns older adults - ✅✅
-Decreased
nutrition and hydration
Decreased mobility
Stress and loss
Accidents - falls most common/MVA
Drug use and misuse
Mental health/cognition problems (including substance abuse)
Elder neglect and abuse
✅✅-inflammation of the vein (redness,
Complication of PIV
phlebitis and thrombophlebitis -
edema, warmth, pain at site)
discontinue IV
notify physician for treatment
restart IV in the opposite extremity
✅✅
Complications of Central Access Device
Air Embolism - -Bolus of air enters circulation
potentially fatal
s/s: tachycardia, chest pain, dyspnea, and cyanosis
interventions: trapping the air into the R atrium, turn the client to the left
side in trendelenberg position
all lines should be primed prior to use and connections secure when not
in use
✅✅-s/s:
Complications of central Line Access
Central line associated blood stream infection (CLABI) -
localized erythema, tenderness, fever, drainage
can lead to a systemic infection and sepsis
d/c the central line and culture the tip
tx: ABT and antifungals
prevention: meticulous hand washing
Adaptive equipment - ✅✅ -buttonhook
extended shoehorn
plate guard and spork
gel pad
foam buildups
hook and loop fasteners
long-handled reacher
elastic shoelaces or velcro shoe closure
Airborne Precautions - ✅✅ -private room with negative pressure
airflow, keep door closed, N95 respirator, patient to wear surgical mask
when leaving room a clinical reason
M - measles
T - tuberculosis
V - varicella (including disseminated zoster)
cane teaching - ✅✅ -- be sure cane is at the height of the patients wrist
when the arm is placed at his or her side
- remind patient to place his or her strong hand on cane
- ensure that the patient's body is well balanced
- move the cane and weaker leg forward at the same time
- move the stronger leg one step forward
- check balance and repeat the sequence
Care of Patient in Sickle Call Crisis -✅✅ -Give prescribed pain
medication
hydrate with normal saline IV, encourage oral intake of fluids without
caffeine
administer oxygen
remove restrictive clothing, no blood pressure with external cuff
check circulation in extremities every hour
✅✅
Cellulitis - -generalized infection with either staphylococcus or
streptococcus and involves deeper connection tissue
infection can spread by scratching or rubbing the skin
,can result from a secondary bacterial infection of an open wound or
unrelated to skin trauma
localized area of inflammation that may enlarge rapidly if not treated
warm compresses to the area are recommended
treatment with IVABT
Central Line Access Devices - ✅✅ -All central line access devices
terminate in the superior vena cava (PICC line, implantable ports,
tunneled and non-tunneled catheters, and central lines)
insertion requires informed consent
need to have a chest x-ray prior to use
Changes in Dark skin - Bleeding - ✅✅ -- Compare the affected area
with the same area on the unaffected body side for swelling or skin
darkening
- if the patient has thrombocytopenia, petechiae may be present on the
oral mucosa or conjunctiva
Changes in Dark skin - cyanosis - ✅✅ -- examine lips and tongue for
gray color
- examine nail beds, palms, and soles for blue tinge
- Examine conjunctiva for pallor
Changes in Dark skin - Inflammation - ✅✅ -- Compare effective area
with non affected area for increased warmth
-examine skin of affected area to determine whether it is shiny or taut or
pits with pressure
- Compare the skin color of affected area with the same area on the
opposite side of the body
- palpate the affected area and compare it with unaffected area to
determine whether texture is different (affected area may feel hard or
"woody"
Changes in Dark skin - Jaundice - ✅✅ -- Check for yellow tinge to oral
mucous membranes, especially the hard palate
- examine the sclera nearest to the iris rather than the corners of the eye
, Chapter 24 - skin layers - ✅✅-- Epidermis
- dermis
- subcutaneous - hypodermis
Common health Issues and Concerns older adults - ✅✅
-Decreased
nutrition and hydration
Decreased mobility
Stress and loss
Accidents - falls most common/MVA
Drug use and misuse
Mental health/cognition problems (including substance abuse)
Elder neglect and abuse
✅✅-inflammation of the vein (redness,
Complication of PIV
phlebitis and thrombophlebitis -
edema, warmth, pain at site)
discontinue IV
notify physician for treatment
restart IV in the opposite extremity
✅✅
Complications of Central Access Device
Air Embolism - -Bolus of air enters circulation
potentially fatal
s/s: tachycardia, chest pain, dyspnea, and cyanosis
interventions: trapping the air into the R atrium, turn the client to the left
side in trendelenberg position
all lines should be primed prior to use and connections secure when not
in use
✅✅-s/s:
Complications of central Line Access
Central line associated blood stream infection (CLABI) -
localized erythema, tenderness, fever, drainage
can lead to a systemic infection and sepsis
d/c the central line and culture the tip
tx: ABT and antifungals
prevention: meticulous hand washing
