verified answers
- Assess and determine who is a higher risk
- Implement priority interventions based on the risk
o Teach patients to do active ROM exercises every 2 hours
o Assess and manage pain to promote more comfortable movement
o Teach patients to perform "heel pump" activities
o Drink adequate fluids to help prevent venous thromboembolism (VTE) such as
deep vein
thrombosis (DVT)
o Evaluate the patient's need for assistive devices with the help of an
Occupational
Therapist to promote ADL independence (plate guard or splint, canes, walkers)
o Encourage ambulation by collaborating with physical therapist. Ans✓✓✓
Interventions to promote mobility
- Monitor labs (albumin & pre-albumin determine malnutrition)
- Ensure proper intake of proteins (Proteins=Building blocks)
- Promote proper hygiene keeping the skin dry and clean
- Inspect skin daily
- Use moisturizers
- Encourage repositions every 1 to 2 hours, especially for chair or bed bound
patients
- Apply pressure redistribution surfaces (mattresses, overlay, or gel pads)
- Use an EB screening tools (Braden scale, Norton, etc)
, - Involved the patient and family in the education and care
- Use an interprofessional approach (nutritionist, physical therapist, occupational
therapist,
wound care specialist, providers, etc)
- Add nutritional protein shakes
- Continue performing reposition, redistribution, hygiene, etc. Ans✓✓✓
Interventions to relieve pressure and maintain skin integrity
- Provide identity and sense of belonging
- Consist of common beliefs & practices
- Material (clothing, art) and non-material (language, beliefs).
- Dynamic & adaptive
- Complex
- Diverse
- Influences thinking and activities Ans✓✓✓ Culture Characteristics
- Scientific (Hospitals, clinics, medications, etc)
o Magico-religious= "alternative or indigenous" (supernatural forces of healing,
rituals).
o Holistic= need for harmony and balance of the body with nature (yoga,
meditation, etc.) Ans✓✓✓ 3 major health beliefs
· Close & supportive extended-family relationships
· Family, unity, loyalty, and cooperation are important.
· Usually matriarchal
· Present oriented