Stuvia-975047-nur-2356-multidimensional-care-exam-3-nur-2356-nur2356mdc-exam-3-review-study-guide.do

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MDC Final Exam Review 1. Appropriate nursing actions: Nicole a) When a client falls 1 st 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. 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 soiling occurs and at routine intervals. Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence. Use tepid rather than hot water. In the perineal area, use a disposable cleaning cloth that contains a skin-barrier agent. While cleaning, use the minimum scrubbing force necessary to remove soil. Gently pat rather than rub the skin dry. Do not use powders or talc directly on the perineum.

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