Environment and Mood
Lighting that is sufficient or comfortable for a person with normal vision to see fine detail.
Adequate Lighting
Any response that is unrelated, incomprehensible, or incoherent; it is not informative with respect to the item being rated.
Nonsensical Response
What are the three components required for developing a Care Plan Goal?
Need 1) Short Term Goal 2) Long Term Goal 3) SMART Goal
A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
DTI-Deep Tissue Injury
Side Effects: Diarrhea, Headache, Rash/Flushing, Throwing Up, Upset Stomach
High Risk Considerations: Risk for Drug-Drug Interaction, Inappropriate use can lead to drug-resistant bacteria, Instruct patients to talk all doses and complete their course of _______.
Antibiotics
The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
Health Literacy
The ability to place oneself in the correct time. Indicate the correct date in current surroundings.
Temporal Orientation
What does SMART goal stand for?
Specific, Measurable, Actionable, Realistic, Timely
Non-viable yellow, tan, gray, green or brown tissue; can be soft, stringy and mucinous in texture.
Where do you indicate a medication review has been completed?
Actual or perceived lack of contact with other people
Social Isolation
A mental disturbance characterized by new or acutely worsening confusion, disordered expression of thoughts, change in level of consciousness or hallucinations
Delirium
When a Care Plan Problem lists Interdisciplinary Team "Grouper" -Who is required to chart and implement these interventions?
RN, LPN, PT, PTA, OT, COTA
A Surgical Wound has a wound bed filled with granulation tissue to the level of the surrounding skin; no dead space, no avascular tissue; no s/s of infection; wound edges are open
Fully Granulating
Side Effects: Blood in stool or urine, Bruising, risk of bleeding, upset stomach
High Risk Considerations: Anemia, monitoring of drug levels, May require diet modifications, Coordination for services for procedures, surgeries and dental work
Anticoagulants
Startles easily to any sound or touch
Vigilant
Very difficult to arouse and keep aroused for the interview
Stupor
On the initial referral, there was an order for SN, PT and OT. Upon the therapy evaluation a Home Health Aide is required. When should the home health aide begin services?
When the order is signed.
>/=25% when wound bed is covered with granulation tissue; there is minimal avascular tissue; no s/s of infection; wound edges open
Early/Partial Granulation
Side Effects: Excessive sweating, Dizzy, Weak, Increased Heart Rate, Being Pale
High Risk Considerations: Inappropriate use can lead to coma or death, Caution patients when skipping meals and taking medication, Check blood levels frequently
Hypoglycemics
Cannot be aroused despite shaking and shouting
Comatose
Behavior tends to come and go and/or increase or decrease in severity.
Fluctuation
What are the 6 required Elements of a Care Plan?
1) Team 2) Problem 3) Goal 4) Intervention 5) Start Date 6) Expected End Date
A surgical site closed primarily (with sutures, staples, or a chemical bonding agent) is generally described in documentation as a surgical wound until __________ has been present for approximately 30 days, unless it dehisces or presents signs of infection.
Re-Epithelialization
Side Effects: Confusion, Dizziness, Drowsiness, and Headache
High Risk Considerations: Symptoms: Fatigue, weakness, hypotension, arrhythmias, seizures
Caregiver involvement recommended, cannot be stopped suddenly, risk for abuse
Adverse effects can include extrapyramidal effects like tremors, and tardive dyskinesia
Anti-Psychotics