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MDC EXAM 3 REVIEW 12-8-19

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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 fo ... r 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 [Show More]

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