Exhibits

For each potential assessment finding, click to specify if the finding is consistent with Crohn’s disease, appendicitis or intussusception. Each finding may support more than 1 disease process.

Rationale:

A. I should visually monitor the client continuously when in mechanical restraints: Continuous visual monitoring is required when a client is placed in mechanical restraints to ensure safety, assess physical and psychological well-being, and promptly address any complications such as impaired circulation or distress.

B. I should ask the provider to write a prescription for mechanical restraints as needed: PRN (as needed) prescriptions for restraints are not permitted. A new, time-limited order must be obtained for each specific episode to ensure proper use and prevent misuse or overuse of restraints.

C. I should expect the provider to evaluate the client within 4 hours of restraint application: For adult clients, the provider must evaluate the client face-to-face within 1 hour of applying restraints, not 4 hours. This rule ensures timely review of the necessity and appropriateness of the intervention.

D. I should assess the client's skin integrity every 8 hours while in mechanical restraints: Skin integrity should be assessed at least every 2 hours or more frequently depending on facility policy. Waiting 8 hours increases the risk of skin breakdown and other complications.

Rationale:

A. Irrigate the wound using a 10 mL syringe: A 10 mL syringe does not provide enough volume or control for effective wound irrigation. Typically, a 30 to 60 mL syringe with an appropriate catheter or tip is used to deliver a steady, low-pressure stream.

B. Cleanse the insertion site of the drain using a circular motion toward the center: Cleansing should be performed from the center outward in circular motions to avoid dragging contaminants toward the wound or drain site. Cleaning toward the center increases the risk of infection.

C. Cleanse the wound starting at the bottom and moving upward: Wound cleansing should be performed from the least contaminated area to the most contaminated — usually from top to bottom or from the incision line outward. Cleaning from bottom to top can introduce bacteria to cleaner areas.

D. Irrigate the wound with a low-pressure flow of solution: Using a low-pressure irrigation helps to flush out debris and reduce bacterial load without damaging healthy tissue or forcing contaminants deeper into the wound. It is the recommended method for safe and effective wound cleansing.