Appropriate nursing actions: Nicole
a) When a client falls
1
st 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
Elevat...
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
c) Fire safety measures and priorities (module 3 slides 12 &22)
o Fires
Home fires are the major cause of death and injuries
Older adults & children < 5y/o have the highest risk.
Most common causes of fires:
Cooking fires
Smoking
Heating Equipment
Home oxygen administration equipment: 75% of home fires involves
oxygen, smoking materials are the ignition source
Remove the client from the area
o RACE
Rescue – remove patient from danger
Alarm – pull the alarm
Contain - close doors
Extinguish fire (if possible)
o PASS
Pull the pin
Aim at the base of the fire
Squeeze the handles
Sweep back and forth
d) Infant safety- education for new moms in keeping babies safe.
Don’t Sleep with baby
Car seat faces backwards for 2 years
Baby should sleep in their back
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