NUR 2356 MDC EXAM 3 REVIEW 12-8-19.
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
...
nur 2356 mdc exam 3 review 12 8 19 mdc final exam review 1 appropriate nursing actions nicole a when a client falls • 1 st priority – check on patient for any injuries before that
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NUR 2356 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?
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