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NUR 2356-MDC Final Exam Review-comprehensive-2022

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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. CONTINUED..... [Show More]

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