nrs 207

Importance of changing the position of dependent patients

-Promotes circulation -Prevents skin breakdown and ulcer formation -Allows for expansion of chest and lungs -Maintains musculoskeletal function -Prevents contractures -Stimulates postural reflexes -Prevent muscle discomfort -Maintain good body alignment

Guidelines for use of restraints

-Use is based on patient's assessed needs -Alternatives should be considered prior to use of restraints, and least restrictive methods should be utilized

Restraint methods

-always tie restraints to bed frame, not side rails! -vest--make sure correct fit for patient, apply over gown -soft lap belt--when patients in chair -soft wrist/ankle restraints--leave room for 2 finger space -side rails--when it restricts the patients movement & patient can't lower it

female perineal care

-assist client into dorsal recumbent position -lower side rail, and help client flex knees and spread legs -wash and dry upper thighs -wash labia majora, wash carefully in skin folds. wipe front to back, repeat on opposite side with different section of washcloth. -wash front to back in labia minor, clitoris, and vaginal orifice. -dry

male perineal care

-assist client into supine position -wash and dry clients upper thighs -gently raise penis, and place bath towel underneath. Gently grasp shaft, if client is uncircumcised, retract foreskin -wash tip of penis first. using circular motion. discard washcloth, and repeat with clean cloth till penis is clean -wash shaft with downward strokes -wash scrotum and underlying skin folds -dry

Principles of correct body mechanics

-face direction of movement to avoid twisting spine -alternate strenuous activity and rest periods -seek assistance with heavy tasks -use assistive devices as necessary -work efficiently

Assessment of patient prior to restraint use

-history of abuse -physical conditions (arthritis, amputations, risk for aspiration) -age related considerations (elderly, pediatric) -cognitively limited patients due to disease processes (alzheimer's, alcohol withdrawal)

Principles of correct body mechanics

-maintain vertical line of body alignment -use a wide base of support (12 in. separation of feet) -maintain a low center of gravity (umbilicus) -use the long muscles of the legs, abdomen, & arms -pull objects toward the center of gravity of the body

Principles of correct body mechanics

-slide, push, or pull rather than lifting (uses less energy) -carry objects close to the body -rock forward/backward to move an object -avoid twisting the thoracolumbar spine or bending waist -decrease friction whenever possible

how to take out dentures

-wash hands and apply gloves -grasp upper plate at front with thumb and index finger wrapped in gauze, and pull downward. -gently lift lower denture from jaw and rotate one side downward to remove from client's mouth. -Place dentures in emesis basin or sink

Pressure Points in supine/dorsal position

Back of head and ears, shoulders, sacrum, elbows, and heels.

Positioning- Supine/Dorsal recumbent

Client is on back with head and shoulders slightly elevated. Be sure pillow is not too thick of it may cause cervical flexion. Use pillows or sandbags to prevent external rotation of extremities. Prevent foot drop with pillow or footboard.

Dangling

Client sits on the bed with legs and feet over side of the bed

Bed positions- Reverse Trendelenburg's

Foot of bed tilted down. Used infrequently. May be used to promote gastric emptying and prevent esophageal reflux.

Bed Positions-Fowlers

Head of bed elevated 45-60 degrees with knees bent. Small pillow under head, lumbar region, and thighs. Prevent foot drop with pillow or footboard. Arms at side if patient is dependent. Sandbags to prevent external rotation of the legs.

Linens necessary to perform a complete bed linen change

Linen bag, mattress pad (changed only when soiled), bottom sheet, draw sheet, top sheet, blanket, bedspread, waterproof pads, pillowcases, bedside chair or table, clean gloves, washcloth, and antiseptic cleanser

Positioning- Prone

On abdomen with head to one side. Small pillow under head and under legs to lift feet and prevent foot drop. Small pillow below diaphragm to prevent lumbar hyperextension. Chest expansion is limited. Not recommended for patients with cardiac, respiratory, or spinal problems.

Positioning- Sims/semiprone

On side but halfway between lateral and prone, 3/4 forward towards stomach. Lower arm behind client. Upper leg flexed with small pillow under it. Pillow under head. Pressure points: ileum and arm

position of a helpless/comatose patient for oral hygiene and why

Position client close to side of bed; turn client's head toward mattress. Client can also be placed on side (Sims' position) -turning the client's head to the side allows secretions to drain from mouth instead of collecting in back of throat. Prevents aspiration. Moving the client close to the side of the bed facilitates proper body mechanics during the skill.

Lithotomy

Recumbent with heels in stirrups

"Putting on the pelvic girdle"

Refers to the tightening of the abdominal muscles to provide a strong core of support for the body.

Pressure Points in lateral position

Side of head, ear, shoulder, hip, and greater trochanter

Positioning- Lateral/side-lying

Side-lying with most weight on the shoulder and hip. Top hip and knee are flexed and in front of body and both arms are flexed in front of body. Pillow under top arm and hip. Watch pressure points. Keep patient forward and off of greater trochanter.

Bed Positions- Trendelenburg's

Tilted with head of bed down. Used infrequently. Promotes venous return. May be used for postural drainage.

Devices to position patients

Trapeze bar--is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. hand rolls-- maintain thumb in slight adduction and in opposition to the fingers, maintains the hand, thumb, and fingers in a functional position. most often used with clients whose arms are paralyzed or who are unconscious

"base of support"

Wide triangle of support. A wider base of support provides stability

how often a patients position should be changed.

at least every 2 hours or more frequently based upon assessment

Fowlers Pressure points

back of head and ears, sacrum, and heels

Partial bed bath

bathing only body parts that would cause discomfort if left unbathed, such as the hands, face, axillae, and perineal area; includes washing back and giving back rub

"center of gravity"

center of the mass; in humans, it is approx. between the umbilicus and the symphysis pubis.

when to not use a straight-edged razor while shaving

clients prone to bleeding (e.g., those receiving anticoagulants or high doses of aspirin or those with low platelet counts)

belt restraints

device that secures client to bed or stretcher. apply over gown. avoid placing belt across the chest or too tightly across the abdomen

Implications for nursing care-skin temp regulation

factors that interfere with heat loss alter temperature control. Wet bed linen or gowns interfere with convection and conduction. Excess blankets or bed coverings interfere with heat loss through radiation and conduction. Coverings promote heat conservation.

Devices to position patients

footboard, wedges, bedboard, hand-wrist splint, draw sheet, mechanical lifts, roller board, and custom made devices to maintain body position & alignment

Three situations in which a back rub would be contraindicated

fractured ribs, burns of the skin, and heart surgery.

purpose of draw sheet/pad

is used to lift and reposition client. Placement under client's torso distributes most of clients body weight over sheet.

Implications for nursing care-skin sensation

minimize friction to avoid loss of stratum corneum, which will result in development of pressure ulcers -smoothing linen removes sources of mechanical irritation -remove rings from fingers to prevent accidentally injuring client's skin -make sure bath water is not excessively hot or cold

Implications for nursing care-skin excretion/secretion

perspiration and oil harbor microorganisms. Bathing removes excess body secretions, although if excessive, it causes dry skin.

Devices to position patients

pillows-- use folded sheets, blankets, or towels if pillows are not available, for pressure points; positioning boots/high-top tennis shoes-- on client's feet to prevent footdrop; ankle-foot orthotic (AFO)-- to help maintain dorsiflexion; a trochanter roll or sand bags-- prevents external rotation of the hips when the client is in supine position

reasons why patient should be kept draped during bath

prevents chilling and exposure of body parts

Three purposes of a back rub

promotes relaxation, relieves muscular tension, and decreases perception of pain.

Four functions of the skin

protection, secretion & excretion, temperature regulation, and sensation

wrist restraints

restraint designed to immobilize one or all extremities. Composed of sheep skin or foam padding. Wrap limb restraint around wrist or ankle with soft part toward skin and secured snugly in place by velcro straps

Bed Positions- Semi-fowlers & high fowlers

semi--about 30 degrees elevation of the head of bed high--about 90 degrees elevation of the head of bed

Muscles that should not be used to lift and move things.

short muscles of the back

Pressure Points in prone position

side of head and ear, breasts of female, hips and knees

Patient complications from inadequate positioning

skin breakdown, pressure ulcers, contractures, pneumonia or other respiratory complications, loss of mobility due to foot drop (plantar flexion), loss of joint function from hyperextension, cervical or lumbar flexion, edema in unsupported body parts.

Body mechanics

the coordinated use of muscles and joints to maintain balance, posture, and body alignment. Movement should be efficient and safe in order to decrease the risk of injury and reduce fatigue.

Usually the correct muscles to use to avoid injury.

the long muscles of the legs, arms, abdomen, and pelvis.

comatose or helpless patients need oral hygiene care more frequently because..

these patients are susceptible to drying of mucous-thickened salivary secretions because they are unable to drink or eat, frequently breath through mouth, and often receive oxygen therapy. They also can't swallow salivary secretions and these secretions often contain gram-negative bacteria

mitt restraints

thumbless mitten device to restrain client's hands. Place hand in mitten, being sure to bring end all the way up over the wrist

Restraint orders must contain..

type of restraint, reason for the restraint, time limited (no more than 24 hours), no standing or PRN orders, must be rewritten every day to continue restraints following examination of the patient

Implications for nursing care-skin protection

weakening of the epidermis occurs by scraping or stripping its surface; excessive dryness causes cracks & breaks in skin that allow bacteria in; constant exposure to moisture causes maceration/softening, which interrupts dermal integrity & promotes ulcer formation & bacteria growth. -Keep bed linen and clothing dry -Cleanse skin

Physician orders for restraints

written or verbal order prior to restraint application -physician assessment must occur within 24 hours