*NURSING > VATI PN > VATI fundamentals focused review | 4 pages (All)

VATI fundamentals focused review | 4 pages

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A client is on strict bedrest and is at risk for skin breakdown. What interventions should the nurse take to maintain this client's skin integrity? As part of the nursing interventions to maintain t ... he client’s skin integrity, the nurse should maintain proper body alignment. The patient should be positioned in rotating side-lying positions every 2 hours. Pillows can be used for support. Nurses should limit the amount of sitting in a chair to 1 hour, using devices to relieve pressure. Nurses should instruct patients to move every 15 minutes if they are able to. Nutritional status should also be monitored, as well as performing skin checks every shift. Suggested Fundamentals Learning Activity: Pressure Ulcers 3. Explain the steps involved in providing an intermittent enteral feeding. For all feedings, prepare the formula, tubing, and infusion device (check expiration dates, ensure the formula is at room temperature, etc.), ensure the client is in a Fowler’s position or at least 30 degrees, auscultate bowel sounds, monitor tube placement (check gastric ph, aspirate residual volume, etc.), flush tubing with at least 30ml of tap water, and then administer the formula. The steps for administering an intermittent enteral feeding formula are: -Prepare the formula and a 60-mL syringe. -Remove the plunger from the syringe. -Hold the tubing above the instillation site. -Open the stopcock on the tubing, and insert the barrel of the syringe with the end up. -Fill the syringe with 40 to 50 mL formula. -If using a feeding bag, fill the bag with the total amount of formula for one feeding, and hang it to drain via gravity until empty (about 30 to 45 min). -If using a syringe, hold it high enough for the formula to empty gradually via gravity. -Continue to refill the syringe until the amount for the feeding is instilled. Follow with at least 30 mL tap water to flush the tube and prevent clogging. [Show More]

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