Question

1. When you go into Mrs. Clement’s room to take her oral temperature, you notice a cup of coffee on her over-bed table. What should you consider, and what should you do?

2. When you report the reddened areas on Mr. Rivera’s knees to the nurse, she thanks you and says that she will go check on Mr. Rivera right away. She says, “Mr. Rivera has so many risk factors for developing pressure ulcers—it’s great that you are paying such close attention to the condition of his skin. We’ll keep a close eye on those areas, and I’ll take

another look at Mr. Rivera’s care plan to make sure we are doing everything we can to protect his skin and lower his risk for developing a pressure ulcer.”

Why could Mr. Rivera easily develop pressure ulcers? Give three reasons. What are some of the actions to help prevent pressure ulcers that you would expect to see

listed on Mr. Rivera’s care plan?

3. As you are helping Mrs. Rider walk to the bathroom so she can brush her teeth before bed, she suddenly sucks in her breath and grabs her side. You ask her if she needs to sit down and she says, “No, I’m fine. I think something I ate at dinner just isn’t agreeing with me. The pain is gone now.” List three questions you would ask Mrs. Rider to gain a better understanding of the pain that she is experiencing.

4. Mrs. Carter has been sitting in a chair watching television for the past 2 hours. When you come to help her change position, she wants to lie on her

back and sleep. What should you do?

Answer 1

1.May Mrs.clement drank coffee, and as coffee contain caffeine may increase body temperature.so, so I recommend waiting 15 to 25 minutes to get accurate reading after that I will take the oral temperature,If She/he drank coffee just before taking of temprature. If not then and I will perform the procedure of taking temperature as usual. I will confirm by asking.

2. Name the three factors that contribute to pressure ulcer with reason are:-

a. Stress-This may be due to related of health or related to disease condition

b. Immobility- this might be due to poor health,Spinal cord injury and other causes.

c. Poor nutrition- there is need enough fluid ,calories, protein ,vitamins and minerals in their daily diet to maintain healthy skin and prevent The breakdown of tissues.

The action to prevent the pressure ulcer are:-

a. Frequently repositioning to reduce or avoid stress on skin

b. Utilize support surfaces on bed and chairs

c. Elevate heels off bed

d. Assist with meals, as needed

e.Maintain good nutrition and fluids by providing sufficient calorie ,adequate protein for positive nitrogen balance, adequate vitamins and minerals, and by encourage adequate daily fluid intake for hydration.

f. Skin assessment by keep skin clean and dry ,protect skin by applying moisturizer, and inspect the skin daily.

g. Offer active or passive range of motion exercises.

3.

i.what makes it hurt more and what helps most

ii.Does the pain affect sleep ,appetite physical activities, relationships with others ,emotions concentration?

iii. How long does it last and Does it come and go or is it there all the time?

4. No I never recommend to her to sleep at the back because she already sit by her back for past 2 hours and at least 6 hours necessary to sleep.So,there will be 6+2 or 8 hours , this will increase the stress on skin and contribute pressure ulcer. So I will convince her to sleep left side because of the layout digestive system and gravity will work in favour on left side as stomach is now positioned below esophagus ,which makes reflux more difficult , and staying left side may cause less compression and less an ulcer pain.