Wound Infection
Give this one a try later!
Symptoms of infection include purulent drainage; increased drainage, pain,
redness, and swelling in and around the wound; increased body
temperature; and increased white blood cell count. Additional signs and
symptoms include delayed healing and discoloration of granulation tissue
in the wound
,Constipation Interventions
Give this one a try later!
Listen to bowel sounds, Laxatives
A combination of high-fiber foods (20 to 35 g of fiber), 60 to 80 oz (1.8 to
2.4 L) of fluid daily, and exercise has been shown to be effective in
controlling constipation in patients with deficiencies in dietary intake of
fiber and/or fluid and reduced amounts of exercise
GT Feeding Residual
Give this one a try later!
Check gastric residual (feeding remaining in the stomach) before each
feeding or every 4 to 6 hours during a continuous feeding (according to
institution policy). High gastric residual volumes (200 to 250 mL or greater)
can be associated with high risk for aspiration and aspiration-related
pneumonia
Pressure Ulcer Stage 1
Give this one a try later!
A stage 1 pressure injury is a defined, localized area of intact skin with
nonblanchable erythema (redness). Darkly pigmented skin may not have
visible blanching; its color may differ from the surrounding skin. The area
may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
,Pressure Ulcer Stage 3
Give this one a try later!
A stage 3 pressure injury presents with full-thickness tissue loss.
Subcutaneous fat may be visible and epibole (rolled wound edges) may
occur, but bone, tendon, or muscle is not exposed. Slough and/or eschar
that may be present do not obscure the depth of tissue loss. Ulcers
Pressure Ulcer Stage 2
Give this one a try later!
A stage 2 pressure injury involves partial-thickness loss of dermis and
presents as a shallow, open ulcer or a ruptured/intact serum-filled blister
Sleep & Exercise
Give this one a try later!
Behavior therapy includes maintaining regular sleep-wake times, avoiding
naps, keeping to a regular exercise routine, and avoiding caffeine, nicotine,
and stimulating activities within several hours of bedtime
Immobility
Give this one a try later!
, Venous stasis and the development of venous thrombosis are potential
complications of immobility. Graduated compression stockings and
pneumatic compression devices are passive interventions prescribed to aid
in the prevention of these complications
Medication Error - Action
Give this one a try later!
-Taking ownership of the error and doing the right thing by putting the
patient first is the only realistic course of action.
-Take immediate corrective measures.
-Inform the patient's doctor of the mistake so that action can be taken as
soon as possible to counteract the effects of the incorrect medication.
PEG Feedings
Give this one a try later!
Placement of a tube into the stomach can be accomplished by a surgeon
or gastroenterologist via a percutaneous endoscopic gastrostomy (PEG) or
a surgically (open or laparoscopically) placed gastrostomy tube. PEG tube
insertion is often used because, unlike a traditional, surgically placed
gastrostomy tube, it usually does not require general anesthesia. Use of a
PEG tube or other type of gastrostomy tube requires an intact, functional
GI tract. Insertion of a PEG tube involves local anesthesia, passage of an
endoscope into the stomach, a small incision or stab wound through the
skin of the abdomen, pushing a cannula through the small incision, insertion
of a guide wire or suture material through the cannula, and introduction
and placement of the PEG tube through one of several method
Give this one a try later!
Symptoms of infection include purulent drainage; increased drainage, pain,
redness, and swelling in and around the wound; increased body
temperature; and increased white blood cell count. Additional signs and
symptoms include delayed healing and discoloration of granulation tissue
in the wound
,Constipation Interventions
Give this one a try later!
Listen to bowel sounds, Laxatives
A combination of high-fiber foods (20 to 35 g of fiber), 60 to 80 oz (1.8 to
2.4 L) of fluid daily, and exercise has been shown to be effective in
controlling constipation in patients with deficiencies in dietary intake of
fiber and/or fluid and reduced amounts of exercise
GT Feeding Residual
Give this one a try later!
Check gastric residual (feeding remaining in the stomach) before each
feeding or every 4 to 6 hours during a continuous feeding (according to
institution policy). High gastric residual volumes (200 to 250 mL or greater)
can be associated with high risk for aspiration and aspiration-related
pneumonia
Pressure Ulcer Stage 1
Give this one a try later!
A stage 1 pressure injury is a defined, localized area of intact skin with
nonblanchable erythema (redness). Darkly pigmented skin may not have
visible blanching; its color may differ from the surrounding skin. The area
may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
,Pressure Ulcer Stage 3
Give this one a try later!
A stage 3 pressure injury presents with full-thickness tissue loss.
Subcutaneous fat may be visible and epibole (rolled wound edges) may
occur, but bone, tendon, or muscle is not exposed. Slough and/or eschar
that may be present do not obscure the depth of tissue loss. Ulcers
Pressure Ulcer Stage 2
Give this one a try later!
A stage 2 pressure injury involves partial-thickness loss of dermis and
presents as a shallow, open ulcer or a ruptured/intact serum-filled blister
Sleep & Exercise
Give this one a try later!
Behavior therapy includes maintaining regular sleep-wake times, avoiding
naps, keeping to a regular exercise routine, and avoiding caffeine, nicotine,
and stimulating activities within several hours of bedtime
Immobility
Give this one a try later!
, Venous stasis and the development of venous thrombosis are potential
complications of immobility. Graduated compression stockings and
pneumatic compression devices are passive interventions prescribed to aid
in the prevention of these complications
Medication Error - Action
Give this one a try later!
-Taking ownership of the error and doing the right thing by putting the
patient first is the only realistic course of action.
-Take immediate corrective measures.
-Inform the patient's doctor of the mistake so that action can be taken as
soon as possible to counteract the effects of the incorrect medication.
PEG Feedings
Give this one a try later!
Placement of a tube into the stomach can be accomplished by a surgeon
or gastroenterologist via a percutaneous endoscopic gastrostomy (PEG) or
a surgically (open or laparoscopically) placed gastrostomy tube. PEG tube
insertion is often used because, unlike a traditional, surgically placed
gastrostomy tube, it usually does not require general anesthesia. Use of a
PEG tube or other type of gastrostomy tube requires an intact, functional
GI tract. Insertion of a PEG tube involves local anesthesia, passage of an
endoscope into the stomach, a small incision or stab wound through the
skin of the abdomen, pushing a cannula through the small incision, insertion
of a guide wire or suture material through the cannula, and introduction
and placement of the PEG tube through one of several method
