- Pressure Injury, Wounds, and Wound Management: Selecting a Dressing for a Stage 2 Pressure
Injury
o Hydrocolloid: occlusive dressing that swells in the presence of exudate; seals the
wound’s surface and prevents evaporation of moisture from the skin
o Maintains a granulating wound bed
o Can stay in place for 3-5 days
- Delegation and Supervision: Tasks to Assign to Assistive Personnel
o Tasks to assign to Aps include ADLs (examples: bathing, grooming, dressing, toileting,
ambulating, feeding if without swallowing precautions, positioning), and routine tasks
(examples: bed making, specimen collection, I/Os, V/S for stable patients)
o The rights of delegation include: risk task, right circumstances, right person, right
direction/communication, right supervision/evaluation
o Determining the right circumstance of evaluation is critical. While a task may be within
an AP’s scope of practice, it may be more appropriate for the nurse to handle the task
depending on circumstance and client’s condition.
- Legal Responsibilities: Teaching About Declining Resuscitation
o A living will is a legal document that expresses the patient’s wishes regarding medical
treatment in the event that the patient becomes incapacitated and is facing end-of-life
issues
o Nurses are responsible for providing written information about advance directives,
document the client’s advance directives status, ensure that the advance directives
reflect the client’s current decisions, and inform all members of the health care team of
client’s advance directives
o Nasal cannula are not considered a resuscitation device but for comfort.
- Admissions, Transfers, and Discharge: Initiating Discharge Planning
o Discharge planning should begin on admission for every client
o Assess whether the patient will be able to return to their previous residence
o Assess the residence to see if patient needs adaptations or specific equipment.
SAFETY AND INFECTION CONTROL
- Sensory Perception: Assessing Safety Risks
o Older adult patients can be increased fall risks because of decreased strength, impaired
mobility and balance, improper use of mobility aids, unsafe clothing, environmental
hazards, endurance limitations, and decreased sensory perception.
o Other patients at increased risk: those with decreased visual acuity, generalized
weakness, urinary frequency, gait and balance problems (i.e. cerebral palsy, injury,
multiple sclerosis), and cognitive dysfunction
o Adverse reactions from meds (orthostatic hypotension, drowsiness, ototoxic) also
increases risk for falls.
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