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NUR 242 Med_Surg Exam 1.
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NUR 242 Med_Surg Exam 1.
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NUR 242 Med/Surg Exam 1Adaptive equipment - ANS-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 - ANS-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 - ANS-- 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 - ANS-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 - ANS-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 - ANS-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 - ANS-- 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 - ANS-- 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 - ANS-- 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 - ANS-- 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 - ANS-- Epidermis
- dermis
- subcutaneous - hypodermis
Common health Issues and Concerns older adults - ANS-Decreased nutrition and
hydration
Decreased mobility
Stress and loss
Accidents - falls most common/MVA
Drug use and misuse
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