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Fundamentals, Exam 2
Immobility
Assessment
Mobility Continuum
Complications
Cardiovascular
Respiratory
Musculoskeletal
Integumentary
Gastrointestinal
Urinary
Considerations
Turn, Cough, Deep Breathe (TCDB)
Range of Motion (ROM)
Skin Care
Fluids
Balanced Diet
2 mins
Interventions for Impaired Skin Integrity
Assessment
Signs of Skin Breakdown
Pain
Redness
Decreased Skin Turgor
Bleeding
Bony Prominences
Intervention
Reposition Q2H
Pressure Relief
Maintain Clean and Dry Skin
Adequate Nutrition and Hydration
2 mins
Patient Position Overview
Position Techniques
Trochanter Roll
Trapeze Bar
Ankle-Foot Orthotic (AFO) Devices
Positions
Fowlers Position
Supine Position
Trendelenburg
Side-Lying Position
Prone Position
Sims' Position
Nursing Considerations
Reposition q2 Hours/Prevent Skin Breakdown
Confirm Body Alignment
2 mins
I-SBAR-R
Identify
Situation
Background
Assessment
Recommendation
Readback
1 min
Aseptic Technique
Invasive Procedures
Skin Integrity Broken
Sterility
Hands Up for Scrubbing
Keep Objects in View
Only Sterile Objects in Field
Only Sterile Touches Sterile
Contamination
Edges of Sterile Field
If Sterility Questioned
If Wet or Prolonged Exposure to Air
Considerations
Never Leave Sterile Area
PPE Order
2 mins
Braden Scale
Characteristics
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
2 mins
Types of Wound Healing
Types of Wounds
Acute
Chronic
Healing Process
Primary Intention
Approximated Edges
Secondary Intention
Edges Not Approximated
Tertiary Intention
Delayed Closure due to Infection and Necrosis
2 mins
Wound Drainage Types and Devices
Drainage Types
Serous
Serosanguineous
Sanguineous
Purulent
Drainage Devices
T-tube
Penrose
Jackson-Pratt (JP)
Hemovac
Considerations
Record Drainage Amounts
Check Device Function
2 mins
Pressure Ulcers
Risk Factors
Prolonged Immobilization
Neurologic Disease
Decreased Level of Consciousness
Classification
Stage 1: Intact Skin with Non-blanchable Erythema
Stage 2: Partial Thickness Skin Loss
Stage 3: Full-thickness Skin Loss without Fascial Involvement
Stage 4: Full-thickness Skin Loss with Fascial Involvement
Management
Wound Care
Surgery
Considerations
Septicemia
Osteomyelitis
Prevention
3 mins
Cane
COAL
Sizing a Cane
Quad Cane
Rubber Tips for Safety
1 min
Walker
Walker with Affected Leg
Sizing a Walker
Rubber Tips for Safety
55 secs
Sizing Crutches
3 Finger Widths
6 Inches Lateral From Heel
30 Degree Flexion
Tripod Position
1 min
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