Exam (elaborations) MDC_EXAM_3_REVIEW_12_8_19.docx

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 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.  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 heelsuspension 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?