NURSING NUR 2356 - MDC EXAM 3 REVIEW 12-8-19. COMPLETE STUDY GUIDE

1. 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 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 pressureredistribution 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