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27 Cards in this Set
- Front
- Back
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Content of daily treatment notes
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Subjective - Pt's response to previous interventions, pt's report of changes in participation or activity limitations
Objective - status update, summarize interventions provided, note that skilled intervention was required to acheive goals Assessment - summarize progress toward pt's goals, factors that modify frequency of intensity of intervention and progression toward anticipated goals Plan - Specific intervention plan for upcoming sessions (incl. why), report what pt will be doing btwn sessions (ex: HEP) Signature/title/name/state/license # |
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Landmines assoc w/ medial record documentation
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Legibility
incompleteness not defending 'medical necessity' according to payers Abbreviations Privacy, Storage, and Retention Not meeting state regulations |
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Washing hands w/ antimicrobial soap and water
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wash 15-60 seconds
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Potential consequences of long term immobility to body systems
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Integumentary - skin breakdown
Cardiopulmonary - edema, deconditioning, decrease air exchange, orthostatic hypotension Neuro - vestibular impairments, decreasedalertness Musculoskel - contractures, calcium loss, deconditioning, loss of balance Other - urinary tract infection (add more) |
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General rules for positining
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change Pt's position EVERY 2 HOURS; more often if problems w/skin
exam skin before placement and RE-EXAMINE SKIN 5-10 MIN AFTER PLACEMENT pt's that sit all day, pressure on buttocks and sacrum relieved every 10-15 min Pt should be DRAPED APPROPRIATELY after positioning Place needed items where they are ACCESSIBLE WRINKLES in sheets, blankets, clothes should be prevented (b/c will make indentations/lines on back from lying on it too long) Sheets and blankets should NOT BE TIGHTLY TUCKED (can cause shearing on skin - not comfortable ) watch for IV, O2, catheter lines - important Position joints in positions that SUPPORT FUNCTION |
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Pressure ulcers
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AKA bed sores; result from lack of blood flow to area resulting in decrease O2 and nutrition of area
Pressure can decrease blood flow causing ischemia areas of bony prominence are most susceptible |
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preventing pressure ulcers
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keep pressure off...etc
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Increased susceptibility to pressure ulcers
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decreased mobility
fragile skin incontinence impaired sensation impaired circulation cachexia (weight loss/muscle wasting) muscle atropy poor postural impairment nutr. deficincy impaired cognition meds that affect mobility/awareness FRICTION OR SHEAR *** |
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potential causes of pressure ulcers
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increased load on reduced surface area
less cushioning, more load more timed, less pressure (low loads over long time period) |
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checking for skin damage (pressure ulcers)
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skin blanching test: when pressed, healthy, lighter colored skin will blanche and quickly return to healthy pink (check on side of skin in contact)
-consider skin temp in high risk areas in dark skinned individuals when placing pt. in new position always check for blancing then check for skin integrity and color after first 5-10 min. **if skin doesn't blanche, indicates compromised tissue (can see skin blanching video clip) |
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contraindications for positioning
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Redness for >20 min after relief - indicates compromised area at high risk for breakdown/ulceration
DO NOT POSITION A PATIENT WITH PRESSURE ON: -a compromised area area still red from previous pos. area where uleration already exists |
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Preventing Contractures
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(muscles, tendons, ligaments stiffen/shorten without motion and limited str.)
Contractures - limitations in joint motion resulting from this shortening *Flexion contractures most common May need to avoid positions of comfort REPOSITION FREQUENTLY |
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Common contractures
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Shoulder flexion
shoulder adduction scap protraction elbow flexion hip flexion hip adduct knee flexion (1 more) |
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preventing edema and cardiopulm complication
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-position distal extremities at or aboe he level of the heart to prevent edema
vary demand on heart by including more upright pos to prevet orthostatic hypotension vary pos. to promote LUNG DRAINAGE |
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Long-term pos. checklist
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clear airway
good spinal alignment pressure over bony prominences minimized shearing minimized support surface cushioned immobile extremeties eleveated contractures prevented appropriate environment (something else*?) |
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Restaints
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ONLY when absolutely necessary
use LEAST RESTRICTIVE DEVICE fasten with quick release buckles or knots monitor pt. closely standards for restraints use are in code of federal regulations *if goal is to limit or restrict pt activity or participation = restraint * if goal is to facilitate participation = not restraint ex: seatbelt on a wheelchair |
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Special precaution
Tube feeding |
keep HOB>30 degrees while feeding and 1 hour after to prevent regurgitation and aspiration
avoid left side lying (prevents stomach from emptying) nasogastric and nasointestinal tubes are secured to nose w/tape and gown or person - AVOID PULLING ON TUBES gastrotomy - surgery...(finish) |
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Oxygen Managemtn
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DO NOT REMOVE O2 DEVICE WITHOUT PERMISSION
never shut off O2 fowf rom wall outlet or tank make sure no kinks in tubing and person not sitting/lying on tubing dont allow tubing to touch flooor* report signs and symptoms of respiratory distress |
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Intravenous Infusion (IV)
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administration of fluid/nutr/medication/blood through needle inserted in vein
if problem occurs w/flow of fluid, alert the nurse careful not to pull IV...this is bad to do (1 mor) |
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Urinary elimination
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Foley catheter - through urethra to bladder
Condom (external) catheter - may loosen easly hanging bag or leg bag KEEP DRAINAGE BAG BELOW BLADDER (mre) |
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Why to drape?
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access body for exam or treatment
protection pt modesty/dignity pt comfort/warmth prot vulnerable sites (wounds/scars/insensae) prot. pt clothing IMPORTANT TO GET TO KNOW PATIENTS SENSE |
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working with survivors of abuse/trauma
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for best outcomes: good communication
informed consent respect for boundaries active pt involvement monitor signs of discomfort |
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cultural sensitivity (draping)
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- trust respect, appreciation of individual differences
there is as much intracultural difference as cross-cultural (dont make assumptions) prefer a same-gender health-care provider. be embarrassed when dressed in a hospital gown. not want to wear attire previously worn by others. have certain items of clothing that are not to be removed |
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maximizing comfort/dignity (draping)
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start with clothing as close to normal clothing as possible - ex: loose pants rather than gown in possible
keep feet covered for warmth/protection - caution: typical socks are slippery and unsafe only use nonslip comm clearly/be secific with pt obs pt's nonverbals provide privacy for changing into/out of garments request permission to reenter room include chaperone shame gender as pt if necessar |
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covering pt (draping)
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gowns - usually open in back, can sometimes
.. |
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linens
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minimize exposure (only 1 area at a time)
layering linens can help minimize exposure secure edges dispose of soiled linens appropriately |
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general procedures
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before: plan ahead, cover table surface, introduce self and get permission, provide temporary clothing or linens, comm what how why, provide privacy
During Minimize exposure throughout Continually adjust and re-secure the draping Instill trust and security in your patient AFTER Provide clean linen to remove gels, etc Provide privacy Dispose of linen appropriately Prepare the room for the next patient |
