NUR 2356 / NUR2356 Multidimensional Care I Exam 3 Review |Latest 2020 |Rasmussen College

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1. Appropriate nursing actions: 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 - 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) f) 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. [Show More]

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