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
•
...
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.
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