MDC EXAM 3 REVIEW 12-8-19

MDC Final Exam Review 1. Appropriate nursing actions: Nicole a) When a client falls • 1st priority – check on patient for any injuries Before that, guide the patient to the floor. b) Positioning to reduce injury for bony prominences • Place pillows under areas and elevate • Changes position for 2hrs Elevate calves to protect heels c) Reducing shear injury (med surg pg 447) • Avoid pulling and sliding patient against bed • Keep head of bed at a slight elevation • Make sure sheets and blankets have ripples in them that rub against the patient’s skin • Use others to assist to protect from shearing. d) Reduce urinary tract infection • Proper cleaning of Perineum – front to back e) Reducing pressure ulcers- factors that are contributors (med surg pg 448) Preventing Pressure Injuries Positioning • Pad contact surfaces with foam, silicone gel, air pads, or other materials with pressure- redistribution properties. • Do not keep the head of the bed elevated above 30 degrees to prevent shearing. • Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her. • When positioning a patient on his or her side, position at a 30-degree tilt. • Re-position an immobile patient at a frequency consistent with assessed needs. • Do not place a rubber ring or donut under the patient's sacral area. • When moving an immobile patient from a bed to another surface, use a designated slide board well lubricated with talc or use a mechanical lift. • Place pillows or foam wedges between two bony surfaces. • Keep the patient's skin directly off plastic surfaces. • Keep the patient's heels off the bed surface using bed pillow under ankles or a heel- suspension device. Nutrition • Ensure a fluid intake between 2000 and 3000 mL/day. • Help the patient maintain an adequate intake of protein and calories. Skin Care • Perform a daily inspection of the patient's entire skin • Document and report any manifestations of skin infection. • Use moisturizers daily on dry skin and apply when skin is damp • Keep moisture from prolonged contact with skin: • Dry areas where two skin surfaces touch, such as the axillae and under the breasts. • Place absorbent pads under areas where perspiration collects. • Use moisture barriers on skin areas where wound drainage or incontinence occurs. • Do not massage bony prominences. • Humidify the room. Skin Cleaning • Clean the skin as soon as possible after soiling occurs and at routine intervals. • Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence. • Use tepid rather than hot water. • In the perineal area, use a disposable cleaning cloth that contains a skin-barrier agent. • While cleaning, use the minimum scrubbing force necessary to remove soil. • Gently pat rather than rub the skin dry. • Do not use powders or talc directly on the perineum. • After cleaning, apply a commercial skin barrier to areas in frequent contact with urine or feces. f) For vital signs out of range (i.e low oxygen saturation) (module 1 slide 56-59) • Normal body temperature 96.4 to 99.5 (depending on the site) • Respiration Rate – 12 to20 breaths per minute • BP – 120/80 and below; anything higher is abnormal • Pulse-Oximetry (saturation) – 94 to 100% • Pulse – 60 to 100 BPM g) Appropriate measures in taking an oral temperature (module 1 slides55) h) Vital signs that can indicate post-surgical pain? • Elevated Heart Rate • Breathing rate can be elevated • Elevated BP 2. Describe the following: Nicole a) Complications of amputations and type of pain (module 1 slide 10) Possibility of phantom pain b) Autonomy for a client requiring oral care (funds book pg 594-595) • Brush the teeth twice a day. • Use a soft toothbrush. • Moisturize oral mucosa and lips every 2 to 4 hours. • Use a chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative period for patients who undergo cardiac surgery (adult patients). • Use mouthwash inside the mouth twice a day for adult patients who are on a ventilator. • Give the patients the oral supplies ....................................................continued...................................................