Nursing Fundamentals ii Multimedia Edition - Introduction
This site has video of many nursing fundamentals that you already know, but may want to confirm you are in fact doing it the right way.
Saturday, March 6, 2010
Wound Dressing
A Post from the EPN discussion Board
- Welcome to your new friend, the CPNE Wound from Hell.
- I use the ribbon method for packing the wound. There is a video or two showing how to do this type of a packing on YouTube.
- I tried the parachute method ... it's too complicated for me. Then again, I can't fold my own dress shirts either.
---------
- Ok. Trick here is, unfold the gauze all the way (you already knew that).
- Next. Fold the gauze (lengthwise) one time, in the middle.
- Next. Lay the gauze in your hand ... really gentle like. Do not squeeze. You want it sort of "fluffy."
- Next. With the end of the gauze sticking out of your hand ... you want to fold back (over itself) about 1/2 inch of that end. You can twist the end if you need too. This will get rid of the little strings at that end.
- Note: Do not make the entire gauze into a "rope." Just the 1/2 inch of your starting piece, so you can get rid of your strings and also get the first corner packed.
- Next. Place that tiny twisted piece in one of the corners. Bingo!!! You've now packed one corner.
- Next. Play out the gauze from your hand. You want
to keep it about 1/2 to 1 inch wide. Then use your index
finger to guide, pack the wound. I go from one end of the wound to the other ... back and forth.
- If you do this right, you will have plenty of gauze for the packing.
- Practice using no gloves. Note: Reusing the same piece of gauze will eventually cause it to become frayed and you'll get 100's of those little strings. Also, watch the boat, as it will get mildew after a week. I learned the hard way.
-You need to practice the wound about 30 minutes a day.
- Just practice the wound packing at first. Yes, you will throw the wound across the room many times. It happens. But, eventually, you will get good at packing the puppy.
- Watch your knuckles, and your thumbs. They seem to come "loose" when you focus on the dressing and not your hands. Knuckles and thumbs hitting the skin seem to be the next hurdle with this puppy.
- Also, copy and paste pictures of the Excelsior Wound on the wall in front of your dressing. It's fun to compare your "masterpiece" to that of the CPNE guidebook.
- Hope this helps.
John Coxey
(Syracuse, NY)
- Welcome to your new friend, the CPNE Wound from Hell.
- I use the ribbon method for packing the wound. There is a video or two showing how to do this type of a packing on YouTube.
- I tried the parachute method ... it's too complicated for me. Then again, I can't fold my own dress shirts either.
---------
- Ok. Trick here is, unfold the gauze all the way (you already knew that).
- Next. Fold the gauze (lengthwise) one time, in the middle.
- Next. Lay the gauze in your hand ... really gentle like. Do not squeeze. You want it sort of "fluffy."
- Next. With the end of the gauze sticking out of your hand ... you want to fold back (over itself) about 1/2 inch of that end. You can twist the end if you need too. This will get rid of the little strings at that end.
- Note: Do not make the entire gauze into a "rope." Just the 1/2 inch of your starting piece, so you can get rid of your strings and also get the first corner packed.
- Next. Place that tiny twisted piece in one of the corners. Bingo!!! You've now packed one corner.
- Next. Play out the gauze from your hand. You want
to keep it about 1/2 to 1 inch wide. Then use your index
finger to guide, pack the wound. I go from one end of the wound to the other ... back and forth.
- If you do this right, you will have plenty of gauze for the packing.
- Practice using no gloves. Note: Reusing the same piece of gauze will eventually cause it to become frayed and you'll get 100's of those little strings. Also, watch the boat, as it will get mildew after a week. I learned the hard way.
-You need to practice the wound about 30 minutes a day.
- Just practice the wound packing at first. Yes, you will throw the wound across the room many times. It happens. But, eventually, you will get good at packing the puppy.
- Watch your knuckles, and your thumbs. They seem to come "loose" when you focus on the dressing and not your hands. Knuckles and thumbs hitting the skin seem to be the next hurdle with this puppy.
- Also, copy and paste pictures of the Excelsior Wound on the wall in front of your dressing. It's fun to compare your "masterpiece" to that of the CPNE guidebook.
- Hope this helps.
John Coxey
(Syracuse, NY)
CPNE FAQs
Subject: CPNE FAQs Topic: CPNE (FAQs)
Author: DARREN WALSH Date: July 31, 2009 8:49 AM
This is a post from Excelsior about the CPNE
FAQS!!! – CPNE
PLEASE NOTE that the questions and answers are also available in a PDF format at the end of this message so you can print them out or save them to your computer.
1. What is included in the 20 minute check?
The 20 minute check occurs after implementation begins, and is preceded by the overriding area of care Asepsis (SG pages 117-119) Caring (SG pages 124-130. This pertains to fluids that are entering the body by intravenous method or enteral feeding and includes: Fluid Management critical element 3 a 1,2,3,4. Also, reference on SG pg. 113
2. Do I have to reidentify the patient each time I leave and enter the room?
No. Identifying the patient MUST occur two times during the PCS: 1. in the area of care Caring (SG p. 124, critical element 1 A,B,C,D, before beginning any required or selected areas of care, and 2. prior to entering the selected area of care medication (SG p. 285) critical element 4 a,b,c. You must also re-identify the patient if you have to hang a new IV bag.
3. Where can I put the paperwork during the PCS?
You could keep it in the pocket of your uniform top or pants. Additionally, the clinical examiner will be able to answer your question as to where to place it if this is not an option.
4. Must there be a barrier between my paperwork and any surface in the room?
No. The clinical examiner will be able to answer your question as to where to place the paperwork in the room.
5. When does Caring come in? Each time I leave and enter the room?
Caring is an overriding area of care (SG pages 124-130.) If you are referring to identifying yourself, the examiner, and the patient, this is done at the beginning of implementation, upon first entering the room. If you are asking about the other critical elements listed in caring, they are to be carried out throughout the PCS and will be evaluated by the clinical examiner. This includes therapeutic communication (element 2), verbal and physical expressions, as well as respect for the client (elements 3, 4 and 5).
6. When can I change a diagnosis to AT RISK and must I use the revised form to do it?
You are not required to make any change to your nursing care plan once the clinical examiner has reviewed it and accepted it in planning. However, should you choose to do so, you may do that at any time during the PCS, once you have determined that the patient’s condition warrants it. (SG pages 112 – 113) At that time, you must show the changes to your clinical examiner by writing them on the revised form, found behind your evaluation phase form in your kardex. Be sure to copy those areas you did not change to facilitate the examiners review of what was changed. The CE will then use the planning phase criteria to re-evaluate your plan.
7. If I have washed my hands, do I have to wash them again after identifying the patient before putting on my gloves to check the IV site?
No. You are expected to wash your hands in order to protect others, yourself and the environment from contamination. No contamination occurred (SG p. 119).
8. Do I have to wash my hands when I take my gloves off after checking the IV site and before touching the tubing?
Yes. The guidelines in the SG pages 120-122 use this as an example. Think about going from a dirty to clean area. The potential exists for contamination from the IV site.
9. For fluid management, how do I convert popsicles and ice chips to fluids?
In many hospitals, there is a conversion sheet that will be provided to you by the clinical examiner. The rule of thumb is one cup of ice chips (a cup that measures 240 ml) is equal to 120 ml. The popsicle wrapper may also provide you with the volume. When in doubt, ask the clinical examiner or staff nurse.
10. What type of fluid is included in intake and output?
Intake you are responsible to record includes: All fluids consumed during the PCS, including the fluids on the breakfast or lunch tray, or what has been taken in during the one hour you have been assigned to measure intake for hourly intake. The volume of the primary IV fluid infused during the PCS when the primary IV fluid has totally infused and the next ordered solution is hung, the IV orders are discontinued, or the patient is on hourly intake; the volume of a secondary IV when it has fully infused. When output is designated, you are to collect and measure all output. Output to measure may include urine, liquid stool, emesis, and chest tube drainage and/or wound or nasogastric secretions. (SG p. 161)
11. Must I keep track of everything that goes in?
Yes, if intake has been designated. (fluids) (SG p. 160)
12. When do I mark the bag so I know what I am responsible for as IV intake?
Page 157 in the study guide states that the student is to determine the amount that is in the bag at the beginning of implementation with the CE. When a new IV needs to be hung, the CE will indicate this in writing on the PCS assignment Kardex. (SG p. 158)
13. How will I know that the CE and I are on the same page for fluids in the bag if I have to change it?
(see above, same answer)
14. When assigned output for children, will I include stool?
Page 162 of the study guide states “Check with the assigned nurse to learn whether formed stool is weighed with the diaper.” On some hospital units the formed stool is removed prior to measuring the diaper weight.
15. When assigned output for children, what if the stool is liquid?
When measuring all output, page 161 of the study guide states: Output to measure may include urine, liquid stool, emesis, chest tube drainage, and/or wound or nasogastric secretions.
16. When do I declare pain level assessment?
If pain level assessment has been assigned under the area of care Vital Signs, you must assess and record this under Vital Signs, and declare it when you declare Vital Signs. (SG p. 176) If you are assigned pain level assessment under the area of care Pain Management, (SG p. 236) you do not have to declare pain level and will be recording it in the narrative notes under Pain Management.
17. What if I am not assigned pain management, will I still have to let the staff nurse know if the number has changed?
Yes. Study Guide pg 176 states: If pain is assessed as part of Vital Signs, and you are not assigned the area of care Pain Management, you are still responsible for intervening in the management of your patient’s pain by reporting the pain level to the staff nurse if indicated.
18. If my diagnoses have changed from planning, can I wait until evaluation to change it if I did the interventions I planned?
Yes. You may change your diagnoses any time during the PCS, including evaluation. (SG pages 112-113). Study guide pg 314 also states: If needed, you may write an entirely new nursing diagnosis and address this as a priority problem in evaluation. Any interventions that are written either in planning or revised during implementation or evaluation must be performed.
19. Do I need to reassess lungs after each intervention (during Respiratory Management), or only at the beginning and end?
The study guide, page 253 states: Immediately following completion of all assigned respiratory hygiene activities, reassess respiratory status with patient in the same position as during initial assessment.
20. Do I have to tell the examiner when I am performing skin turgor assessment or assessing peripheral pulses?
You do not have to verbalize what you are doing to the examiner, however, study guide pg 152 states: Since the assessment of hydration status may be done unobtrusively, be obvious in your actions when performing this assessment and verbalize your findings to alert the CE that you are completing the critical elements. The same is true for pulses.
21. When performing an abdominal assessment, do I have to interrupt the tube feeding?
The SG p. 181 states to turn off the suction machine while auscultating bowel sounds, however, there is nothing to indicate the need to interrupt the tube feeding.
22. If the patient has a nasogastric tube, can I put them flat to do the abdominal assessment?
Yes. If the patient is on suction, you must turn off the suction while auscultating bowel sounds, however, there is nothing in the study guide to support not putting them flat. (SG p. 181) If the patient has a tube feeding via a nasogastric tube, you cannot put them flat, but must keep the head of the bed elevated at least 30 degrees.
23. If the patient is on continuous suction, do I need to interrupt the suction to listen to bowel sounds?
Yes. (See above explanation)
24. If I forget to do a part of an area of care, can I go back into the room during evaluation and if so does the 20 minute check start again?
You may go back into the room if you recognize that you have forgotten something during evaluation. The “20 minute check” only related to fluids in the beginning of implementation. (SG p. 113) You can only be evaluated once on any critical element, therefore, there would be no reason for redoing this check
25. How many repetitions must I do when assigned ROM? The text reference says 3-5 and the study guide states 1.
Study Guide page 220 states: When ROM is designated, you will be expected to direct or assist the patient to perform at least one pair of the following movements: abduction and adduction; flexion and extension. All joints of the designated extremity (ies) are assessed.
26. Is it OK to put tabs in our care plan book and medication book and write what area the tabs are indicating? Can we do this before coming to the CPNE?
Yes.
27. Is it acceptable to highlight our kardex in order to keep us focused during the PCS?
Yes. Some students create their organizational plan on the Kardex as well.
28 . If the clinical examiner indicates one area to assess under skin assessment, do we have to choose two more?
No. Study guide, p. 208 states: Assess a minimum of two vulnerable skin surfaces from the list. You must do two. (the study guide does not state that the Clinical examiner may assign one and you have to choose one more, nor does it state that if the examiner does not indicate any but assigns skin assessment, you will choose two).
29. When may I identify the patient at the lab stations that require identification?
The study guide states, in the simulation lab (pages 359, 361, 370, p. 379) you are to identify this “patient:” immediately before administering the medication.
Attachments: CPNE_FAQS_updated.pdf;
Messages in the thread Display Complete Thread
Name Author Date
CPNE FAQs DARREN WALSH July 31, 2009 8:49 AM
Author: DARREN WALSH Date: July 31, 2009 8:49 AM
This is a post from Excelsior about the CPNE
FAQS!!! – CPNE
PLEASE NOTE that the questions and answers are also available in a PDF format at the end of this message so you can print them out or save them to your computer.
1. What is included in the 20 minute check?
The 20 minute check occurs after implementation begins, and is preceded by the overriding area of care Asepsis (SG pages 117-119) Caring (SG pages 124-130. This pertains to fluids that are entering the body by intravenous method or enteral feeding and includes: Fluid Management critical element 3 a 1,2,3,4. Also, reference on SG pg. 113
2. Do I have to reidentify the patient each time I leave and enter the room?
No. Identifying the patient MUST occur two times during the PCS: 1. in the area of care Caring (SG p. 124, critical element 1 A,B,C,D, before beginning any required or selected areas of care, and 2. prior to entering the selected area of care medication (SG p. 285) critical element 4 a,b,c. You must also re-identify the patient if you have to hang a new IV bag.
3. Where can I put the paperwork during the PCS?
You could keep it in the pocket of your uniform top or pants. Additionally, the clinical examiner will be able to answer your question as to where to place it if this is not an option.
4. Must there be a barrier between my paperwork and any surface in the room?
No. The clinical examiner will be able to answer your question as to where to place the paperwork in the room.
5. When does Caring come in? Each time I leave and enter the room?
Caring is an overriding area of care (SG pages 124-130.) If you are referring to identifying yourself, the examiner, and the patient, this is done at the beginning of implementation, upon first entering the room. If you are asking about the other critical elements listed in caring, they are to be carried out throughout the PCS and will be evaluated by the clinical examiner. This includes therapeutic communication (element 2), verbal and physical expressions, as well as respect for the client (elements 3, 4 and 5).
6. When can I change a diagnosis to AT RISK and must I use the revised form to do it?
You are not required to make any change to your nursing care plan once the clinical examiner has reviewed it and accepted it in planning. However, should you choose to do so, you may do that at any time during the PCS, once you have determined that the patient’s condition warrants it. (SG pages 112 – 113) At that time, you must show the changes to your clinical examiner by writing them on the revised form, found behind your evaluation phase form in your kardex. Be sure to copy those areas you did not change to facilitate the examiners review of what was changed. The CE will then use the planning phase criteria to re-evaluate your plan.
7. If I have washed my hands, do I have to wash them again after identifying the patient before putting on my gloves to check the IV site?
No. You are expected to wash your hands in order to protect others, yourself and the environment from contamination. No contamination occurred (SG p. 119).
8. Do I have to wash my hands when I take my gloves off after checking the IV site and before touching the tubing?
Yes. The guidelines in the SG pages 120-122 use this as an example. Think about going from a dirty to clean area. The potential exists for contamination from the IV site.
9. For fluid management, how do I convert popsicles and ice chips to fluids?
In many hospitals, there is a conversion sheet that will be provided to you by the clinical examiner. The rule of thumb is one cup of ice chips (a cup that measures 240 ml) is equal to 120 ml. The popsicle wrapper may also provide you with the volume. When in doubt, ask the clinical examiner or staff nurse.
10. What type of fluid is included in intake and output?
Intake you are responsible to record includes: All fluids consumed during the PCS, including the fluids on the breakfast or lunch tray, or what has been taken in during the one hour you have been assigned to measure intake for hourly intake. The volume of the primary IV fluid infused during the PCS when the primary IV fluid has totally infused and the next ordered solution is hung, the IV orders are discontinued, or the patient is on hourly intake; the volume of a secondary IV when it has fully infused. When output is designated, you are to collect and measure all output. Output to measure may include urine, liquid stool, emesis, and chest tube drainage and/or wound or nasogastric secretions. (SG p. 161)
11. Must I keep track of everything that goes in?
Yes, if intake has been designated. (fluids) (SG p. 160)
12. When do I mark the bag so I know what I am responsible for as IV intake?
Page 157 in the study guide states that the student is to determine the amount that is in the bag at the beginning of implementation with the CE. When a new IV needs to be hung, the CE will indicate this in writing on the PCS assignment Kardex. (SG p. 158)
13. How will I know that the CE and I are on the same page for fluids in the bag if I have to change it?
(see above, same answer)
14. When assigned output for children, will I include stool?
Page 162 of the study guide states “Check with the assigned nurse to learn whether formed stool is weighed with the diaper.” On some hospital units the formed stool is removed prior to measuring the diaper weight.
15. When assigned output for children, what if the stool is liquid?
When measuring all output, page 161 of the study guide states: Output to measure may include urine, liquid stool, emesis, chest tube drainage, and/or wound or nasogastric secretions.
16. When do I declare pain level assessment?
If pain level assessment has been assigned under the area of care Vital Signs, you must assess and record this under Vital Signs, and declare it when you declare Vital Signs. (SG p. 176) If you are assigned pain level assessment under the area of care Pain Management, (SG p. 236) you do not have to declare pain level and will be recording it in the narrative notes under Pain Management.
17. What if I am not assigned pain management, will I still have to let the staff nurse know if the number has changed?
Yes. Study Guide pg 176 states: If pain is assessed as part of Vital Signs, and you are not assigned the area of care Pain Management, you are still responsible for intervening in the management of your patient’s pain by reporting the pain level to the staff nurse if indicated.
18. If my diagnoses have changed from planning, can I wait until evaluation to change it if I did the interventions I planned?
Yes. You may change your diagnoses any time during the PCS, including evaluation. (SG pages 112-113). Study guide pg 314 also states: If needed, you may write an entirely new nursing diagnosis and address this as a priority problem in evaluation. Any interventions that are written either in planning or revised during implementation or evaluation must be performed.
19. Do I need to reassess lungs after each intervention (during Respiratory Management), or only at the beginning and end?
The study guide, page 253 states: Immediately following completion of all assigned respiratory hygiene activities, reassess respiratory status with patient in the same position as during initial assessment.
20. Do I have to tell the examiner when I am performing skin turgor assessment or assessing peripheral pulses?
You do not have to verbalize what you are doing to the examiner, however, study guide pg 152 states: Since the assessment of hydration status may be done unobtrusively, be obvious in your actions when performing this assessment and verbalize your findings to alert the CE that you are completing the critical elements. The same is true for pulses.
21. When performing an abdominal assessment, do I have to interrupt the tube feeding?
The SG p. 181 states to turn off the suction machine while auscultating bowel sounds, however, there is nothing to indicate the need to interrupt the tube feeding.
22. If the patient has a nasogastric tube, can I put them flat to do the abdominal assessment?
Yes. If the patient is on suction, you must turn off the suction while auscultating bowel sounds, however, there is nothing in the study guide to support not putting them flat. (SG p. 181) If the patient has a tube feeding via a nasogastric tube, you cannot put them flat, but must keep the head of the bed elevated at least 30 degrees.
23. If the patient is on continuous suction, do I need to interrupt the suction to listen to bowel sounds?
Yes. (See above explanation)
24. If I forget to do a part of an area of care, can I go back into the room during evaluation and if so does the 20 minute check start again?
You may go back into the room if you recognize that you have forgotten something during evaluation. The “20 minute check” only related to fluids in the beginning of implementation. (SG p. 113) You can only be evaluated once on any critical element, therefore, there would be no reason for redoing this check
25. How many repetitions must I do when assigned ROM? The text reference says 3-5 and the study guide states 1.
Study Guide page 220 states: When ROM is designated, you will be expected to direct or assist the patient to perform at least one pair of the following movements: abduction and adduction; flexion and extension. All joints of the designated extremity (ies) are assessed.
26. Is it OK to put tabs in our care plan book and medication book and write what area the tabs are indicating? Can we do this before coming to the CPNE?
Yes.
27. Is it acceptable to highlight our kardex in order to keep us focused during the PCS?
Yes. Some students create their organizational plan on the Kardex as well.
28 . If the clinical examiner indicates one area to assess under skin assessment, do we have to choose two more?
No. Study guide, p. 208 states: Assess a minimum of two vulnerable skin surfaces from the list. You must do two. (the study guide does not state that the Clinical examiner may assign one and you have to choose one more, nor does it state that if the examiner does not indicate any but assigns skin assessment, you will choose two).
29. When may I identify the patient at the lab stations that require identification?
The study guide states, in the simulation lab (pages 359, 361, 370, p. 379) you are to identify this “patient:” immediately before administering the medication.
Attachments: CPNE_FAQS_updated.pdf;
Messages in the thread Display Complete Thread
Name Author Date
CPNE FAQs DARREN WALSH July 31, 2009 8:49 AM
Selected Areas of Care - Oxygen Management
Oxygen Management - from Excelsior College Flash Cards 2005
SOAPI
Skin assessment around ears and nares
Oxygen saturation/flow rate/percentage
Activity tolerance
Postion to facilitate respirations - pattern of respirations
Ignition sources
- Assesses the patient's response to activity level
- Assesses oxygenation status by
- inspecting nailbeds for color, capillary refill, or clubbing or
- measuring oxygen saturation level when assigned
- Assesses skin surfaces in contact with oxygen delivery system
- Positions the patient to facilitate respiration
- Sets, adjusts, or maintains oxygen flow at designated rate (liters or percent)
- Maintains humidification of oxygen if humidification is present
- Removes articles, if present, which can produce a spard or flame from bedside area
- Applies, inserts, or maintains device to deliver oxygen, at the designated rate when required
- Applies and maintains instrument to measure oxygen saturation level when assigned
- Records
- data related to each of the above assessment findings
- response to activity level
- oxygenation status
- condition of skin surfaces in contact with oxygen delivery system
- oxygenation management measures implemented
- patient response to measures implemented
SOAPI
Skin assessment around ears and nares
Oxygen saturation/flow rate/percentage
Activity tolerance
Postion to facilitate respirations - pattern of respirations
Ignition sources
Selected Areas of Care - Musculoskeletal Management
Musculoskeletal Management
BEAMR MAP
Balance
Extraneous movement
Assistive devices
Moved where
Response
Movement
Abnormalities
Pain
MAP HATR (think of a muscular mad hatter from Alice in Wonderland)
Mobility status
Abnormalities
Pain with movement
Heat or cold
Apply devices (like knee brace) if needed
Traction - just make sure the lines are unobstructed, weight hans free
Range of motion - passive or active as directed by CE
- Assess the affected area of designated extremity(ies) for:
- presence or absence of abnormalities (e.g. atrophy)
- level of mobility
- pain with movement
- Directs the patient to move the joints of the designated extremity(ies) through active range of motion by including at least one pair of the following:
- abduction and adduction or
- flexion and extention OR
- Performs passive range of motion by
- moving the joints of the designated extremity(ies) though range of motion at least once by including at least one pair of the following:
- abduction and adduction or
- flexion and extention
- supporting the weight of the extremity at joints during range of motion
- Applies supportive or therapeutic devices to the designated body part(s)
- Applies heat or cold when assigned by
- protecting the skin surface of the body part to be treated
- applying treatment to the designated body part to be treated
- applying treatment at the designated temperature (approximate)
- maintaining treatment for at least 20 minutes unless otherwise designated
- Maintains prescribed traction by
- verifying the prescribed traction weight
- assuring that ropes are unobstructed
- assuring theat weights are hanging freely
- positioning the patient to provide countertraction
- maintaining the patient in the correct alignment
- Records
- data related to
- presence or absence of abnormalities (e.g. atrophy) of the designated extremity(ies)
- level of mobility of the of the designated extremity(ies)
- pain with movement of the designated extremity(ies)
- musculoskeletal measures implemented
- patient response(s) to measures implemented
BEAMR MAP
Balance
Extraneous movement
Assistive devices
Moved where
Response
Movement
Abnormalities
Pain
MAP HATR (think of a muscular mad hatter from Alice in Wonderland)
Mobility status
Abnormalities
Pain with movement
Heat or cold
Apply devices (like knee brace) if needed
Traction - just make sure the lines are unobstructed, weight hans free
Range of motion - passive or active as directed by CE
Selected Areas of Care Comfort Management
Comfort Management
Comfort measures - do 3
Oobserve for discomfort
Meds - PRN
Face wash
Oral care
Relaxation
Treat with heat or cold
Evaluate comfort at end
Reposition
Simple back rub
- Assess comfort needs by
- Asking the patient to describe confort needs or
- Observing behaviors indicative of discomfort
- Provides three of the following comfort measures:
- assist the patient with washing face, hands, and/or vulnerable skin surfaces
- repositions or assists the patient to a different postion
- gives the patient a backrub
- uses relaxation and/or distraction techniques
- applies heat or cold when assigned
- assists the patient with mouth care
- changes or adjusts bed linens
- administers medication(s) when assigned
- Records
- data related to comfort needs or disconfort
- comfort measures implemented
- patient response(s) to measures implemented
Comfort measures - do 3
Oobserve for discomfort
Meds - PRN
Face wash
Oral care
Relaxation
Treat with heat or cold
Evaluate comfort at end
Reposition
Simple back rub
Selected Area of Care - Skin Assessment
Skin Assessment
Mneumonic -
TIME to check Color of skin
Temperature
Integrity
Moisture
Edema
Color
- Based on your patient's condition, assesses a minimum of two vulnerable skin surfaces for the list:
- heels
- sacral/coccyx
- occiput
- trochanters
- skinfolds
- peri anal
- designated area(s)
- for -
- color changes
- integrity (e.g. lesions, ras, shear and pressure effects, skin tears)
- temperature
- edema
- moisture (e.g. perspiration, incontinence, diarrhea, non intact ostomy/drainage system)
- Records assessment data of two vulnerable skin surfaces including any designated area(s) related to:
- color changes
- integrity (e.g. lesions, ras, shear and pressure effects, skin tears)
- temperature
- edema
- moisture (e.g. perspiration, incontinence, diarrhea, non intact ostomy/drainage system)
Mneumonic -
TIME to check Color of skin
Temperature
Integrity
Moisture
Edema
Color
Subscribe to:
Posts (Atom)