Documenting wound
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location
shape
size - length, width, depth
stage
integrity - undermining, tunneling
exudate
edges
periwound skin (skin surrounding the wound)
Stool softeners
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, Increase amount of water and fat your stool absorbs
Legal considerations
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conset
client makes decisions (if able)
living will - states clients wishes about healthcare when unable to make
own decisions
Psychosocial
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loss of independence, self esteem
depression
isolation
body image
UTI
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, -Caused by incorrect hygiene
-Nosocomial, bacteriua, urosepsis
-Can be asymptomatic in the elderly
Stage 4
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4 - full thickness tissue loss, can see bone/ tendon/ muscle, dead skin
tissue coming off, undermining and tunneling
Skin assessment - bony prominence
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supine - occiput, sacrum, heels
sitting - ischial tuberosities, coccyx
side-lying - trochanters
Kidney function
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Remove waste from blood to form urine
, Risk of aspiration
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decrease LOC
decrease gag/ cough reflex
hard to manage saliva
PRN ordrers
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only to be given when client requires it
Factors influencing urination
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-Disease / conditions (ex: diabetes)
-Medication
-Socioeconomic (privacy)
-Psychological factors
-Fluid balance: nocturnal, polyuria, oliguria, anuria
-Fever
Skin integrity stages
Give this one a try later!
Give this one a try later!
location
shape
size - length, width, depth
stage
integrity - undermining, tunneling
exudate
edges
periwound skin (skin surrounding the wound)
Stool softeners
Give this one a try later!
, Increase amount of water and fat your stool absorbs
Legal considerations
Give this one a try later!
conset
client makes decisions (if able)
living will - states clients wishes about healthcare when unable to make
own decisions
Psychosocial
Give this one a try later!
loss of independence, self esteem
depression
isolation
body image
UTI
Give this one a try later!
, -Caused by incorrect hygiene
-Nosocomial, bacteriua, urosepsis
-Can be asymptomatic in the elderly
Stage 4
Give this one a try later!
4 - full thickness tissue loss, can see bone/ tendon/ muscle, dead skin
tissue coming off, undermining and tunneling
Skin assessment - bony prominence
Give this one a try later!
supine - occiput, sacrum, heels
sitting - ischial tuberosities, coccyx
side-lying - trochanters
Kidney function
Give this one a try later!
Remove waste from blood to form urine
, Risk of aspiration
Give this one a try later!
decrease LOC
decrease gag/ cough reflex
hard to manage saliva
PRN ordrers
Give this one a try later!
only to be given when client requires it
Factors influencing urination
Give this one a try later!
-Disease / conditions (ex: diabetes)
-Medication
-Socioeconomic (privacy)
-Psychological factors
-Fluid balance: nocturnal, polyuria, oliguria, anuria
-Fever
Skin integrity stages
Give this one a try later!
