NURSING NUR2356 - MDC EXAM 3 REVIEW 12-8-19.

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 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
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