Evaluating the Client''s correct body alignment Maintain/correct the adjustment of client''s response to interventions to prevent complications from immobility Identifying the Complications of Immobility
DIY Bunker Boxhow to DIY Bunker Box for The hazards or complications of immobility, such as skin breakdown, pressure ulcers, contractures, muscular weakness, muscular atrophy, disuse osteoporosis, renal calculi, urinary stasis, urinary retention, urinary incontinence, urinary tract infections, atelectasis, pneumonia, decreased respiratory vital capacity, venous stasis, venous insufficiency, orthostatic hypotension, decreased cardiac reserve, edema, emboli, thrombophlebitis, constipation and the loss of calcium from the bones, are highly costly in terms of health care dollars and in terms of client suffering. Many of these costly complications of immobility can, and should be, prevented whenever possible.
DIY Bunker Boxhow to DIY Bunker Box for Immobility and complete bed rest can lead to life threatening physical and psychological complications and consequences. Members of the nursing care team and other health care professionals like physical therapists must, therefore, promote client mobility and prevent immobility whenever possible. Immobility can adversely affect all physiological bodily systems.
The complications and hazards associated with immobility and according to bodily system are described below:
As the result for 1 last update 2020/06/04 of immobility, the urinary system can be adversely affected with urinary retention, urinary stasis, renal calculi, urinary incontinence and urinary tract infections.As the result of immobility, the urinary system can be adversely affected with urinary retention, urinary stasis, renal calculi, urinary incontinence and urinary tract infections.
Constipation, impaction and difficult to evacuate for 1 last update 2020/06/04 feces can occur as the result of immobility and the lack of exercise that is needed to promote normal bowel functioning. These bowel alterations are further confounded when the client is not getting adequate fluid intake.Constipation, impaction and difficult to evacuate feces can occur as the result of immobility and the lack of exercise that is needed to promote normal bowel functioning. These bowel alterations are further confounded when the client is not getting adequate fluid intake.
The muscles, joints and bones are adversely affected by immobility.
The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse osteoporosis, hypercalcemia, and fractures. At times a tilt table can be used to prevent this damage by placing the client in a position of weight bearing to avoid these complications.
The joints are affected with stiffness, pain, impaired range of motion and contractures including foot drop which is a plantar flexion contracture. Some of these joint disorders can be prevented with frequent and proper positioning of the client in correct bodily alignment, the provision of range of motion exercises to all joints several times a day, and the use of devices like a hand roll and a bed board to prevent contractures of the hands and feet, respectively.
Muscles are adversely affected with weakness and atrophy as the result of immobility. These hazards of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic, isometric and isokinetic muscular exercises.
DIY Bunker Boxhow to DIY Bunker Box for Some adverse respiratory system effects relating to immobility include the thickening of respiratory secretions, the pooling of respiratory secretions and an increased inability of the client to mobilize and expectorate these secretions, all of which can lead to atelectasis, hypostatic pneumonia, and respiratory tract infections. Immobility can also lead to shallow, ineffective respirations, decreased respiratory movement, and a decrease in terms of the client''s movements and mobility and using some standardized tests such as the Timed Get Up and Go Test with which the nurse assesses the client''s ability to sit and then stand, march in place and advance forward with each foot and return to the same position. These and even more complex and advanced standardized tests and tools are also used during a physical therapist''s cochlea, poor posture, and a musculoskeletal or neurological disorder; muscular coordination is the ability of the person to smoothly and safely use gross motor and fine motor coordination. Coordination can be adversely affected with a neurological disorder of the cerebellum, cerebral cortex and basal ganglia; muscular strength can be impaired with things like muscular atrophy, spasticity, nutritional deficits, paresis, flaccidity and other causes; and joint mobility can be impaired disuse, arthritis and other disorders of the bone.
Muscular strength is classified on a scale of zero to five, as below.
Zero: No muscular contraction One: No muscular movement, only a quiver is noted Two: Muscular movement but only when assisted with gravity Three: Muscular movement against gravity but not against resistance Four: Muscular movement against resistance Five: Full muscular movement and strength
Joint mobility and range of motion are assessed for the client. Simply defined, full range of motion is defined as the maximum movement of a joint specific to that joint. For example, the elbow should normally be able to perform extension, flexion, rotation for supination and notation for pronation and the neck should be fully able to perform extension, flexion, lateral flexion, hyperextension and rotation.
After the client is assessed, the mobility of the client, in addition to other functional activities, can be graded and classified as follows in terms of this level of functional ability:
Level 0: The client is completely independent in terms of mobility Level 1: The client needs an assistive device Level 2: The client needs an assistive device and the coaching and supervision of another person Level 3: The client needs an assistive device and the direct assistance of another person Level 4: The client is totally dependent on others for their mobility needs Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown Skin Assessment
The skin, which is the first line of defense against infection, should be intact and not broken, it should be warm and without any excessive moisture, and the skin should also have good elasticity, which is referred to as good skin turgor.
Some of the factors that impact on the skin and its integrity include intrinsic and extrinsic factors and forces. Some of these intrinsic factors include the client''s perfusion and peripheral circulation, some of the normal changes of the aging process, cachexia and emaciation, an alteration in terms of the client''s body build as well as the size of their boney prominences.
Some of the extrinsic factors that impact on the skin and its integrity are environmental humidity, chemical irritants, extremes in terms of hot and cold weather, radiation, and mechanical forces such as pressure, shearing and friction
Some of the nursing diagnoses related to skin and skin integrity can include:
At risk for impaired skin integrity related to immobility At risk for impaired skin integrity related to poor skin turgor Impaired skin integrity related to impaired tissue perfusion At risk for impaired skin integrity related to boney prominences Impaired skin integrity related to pressure, shearing and friction Impaired skin integrity related to poor nutritional status
All skin areas that are not within normal limits and indicate any signs of skin breakdown are assessed and described according to its color, size, location, odor, drainage, margins, texture, distribution and underlying bed tissue.
The skin is described in terms of its color which can be yellow, ecchymosed, purple, green, blanched and reddened, for example.
The area of an abnormality is measured with a disposable rule in terms of centimeters. The length and width of all areas are measured and the depth of wounds is also measured. The depth of a wound is measured using a sterile cotton applicator which is then compared to the disposable rule for an accurate measurement. After the wound is assessed and measured, the wound dimension is calculated by multiplying the length by the width by the depth of the wound. For example when the length of the sound is 4 cm and the width of the wound is 3 cm and the depth of the wound is 1 cm, the wound dimension is 12 cm because 4 x 3 x 1 = 12 cm.
The skin area that has impaired skin integrity is also described according to its exact location and in reference to its anatomical location. For example, an area of skin breakdown can be described as on the posterior of the arm just inferior to the elbow or over the sacrum and coccyx. Some assessment forms allow the nurse to draw the area of concern on it to graphically show both the location and the relative size of the skin area that is affected with impaired skin integrity.
Some wounds and wound drainage have odors and others do not. Odors can be described as malodorous, pungent, foul, or musty; and some pathogens like pseudomonas have a characteristic odor.
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Wound discharge, which is also referred to as wound exudate, is assessed and described as the lack of any drainage or the presence of some drainage which be described in terms of color, amount and characteristics.
The quantity or amount of drainage can be described as minimal, moderate or excessive and copious when a wound drain is not being used to measure drainage precisely. Wound drainage is also described in terms of its color and characteristics. For example, serous drainage is clear or a slight yellowish color because it consists of serum which is the clear portion of the blood; sanguineous drainage is bloody and red because it consists of red blood cells; serosanguinous drainage is pinkish in color because it is a combination of serum and red blood cells; and purulent drainage can be yellow, green, rust color or brown and this drainage indicates the presence of infection and thick pus.
Affected skin areas can be assessed and described as macerated, edematous, swollen, indurated or normal.
The distribution of impaired skin integrity can be described as generalized and across many areas of the body, localized to one area of the body, asymmetrical and on only one side of the body and also symmetrical which affects both sides of the body bilaterally.
The margins around the wound are also assessed and described in terms of their color, their characteristics and their texture which can be classified and documented as macerated, edematous, swollen, indurated or normal. Wound margins can be described as open, attached, unattached, well defined and with a for 1 last update 2020/06/04 healing ridge.The margins around the wound are also assessed and described in terms of their color, their characteristics and their texture which can be classified and documented as macerated, edematous, swollen, indurated or normal. Wound margins can be described as open, attached, unattached, well defined and with a healing ridge.
Underlying Bed Tissue:
Underlying bed tissue reflects the extent to which the wound is healing, regenerating and renewing. The stages of wound healing are the homeostasis phase, the inflammation phase which is also referred to as the exudate and lag phase, the proliferative and granulation phase, and the maturation phase.
The homeostasis phase is marked with vasoconstriction, platelet formation, thrombin formation and the formation of a fibrin mesh for healing; the inflammation phase is characterized with the signs and symptoms of inflammation including edema, swelling, pain, in addition to the beginning of debris removal to prevent infection through the process of phagocytosis; the proliferative and granulation phase is marked with the fibroblastic production of collagen and granulation tissue; and, lastly, the maturation phase of wound healing is characterized with the still fragile skin after the wound healing process that can last up to two years after a wound. The wound remains vulnerable to injury until full healing is completed with good tensile strength.
Some wounds, like surgical incisions, are planned wounds and others such as those occurring secondary to a trauma or a pressure ulcer are considered unplanned wounds. Nurses assess wounds in respect to their type of wound as well as the other factors discussed above.
DIY Bunker Boxhow to DIY Bunker Box for The three types of wound healing are primary intention healing, secondary intention healing and tertiary intention healing.
Primary Intention Healing
Primary intention healing is facilitated with wounds without infection. The wound edges are approximated and closed with a closure technique such as suturing, Steri Strips, and surgical glues. An example of primary intention healing is the suturing of an abdominal surgical wound after an appendectomy or the suturing of a traumatic laceration with Steri Strips or sutures when this traumatic wound is free of any contamination and infection.
Secondary Intension Healing
Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. These open wounds are irrigated with a sterile solution and then packed to keep them open and, over time, they will heal on their own. The resulting scar is more obvious than those scars that result from primary intention healing.
Tertiary Intension Healing
Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of secondary and primary healing. Tertiary intention healing begins with several days of open wound irrigations and packing, which is secondary healing, followed by the closure of the wound edges with approximation and suturing which is primary healing. Some traumatic wounds are healed with tertiary intention.
Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown
Nurses maintain skin integrity and prevent skin breakdown in a number of different ways. These efforts are even more intense and comprehensive when the client has one or more risk factors associated with impaired skin integrity, as discussed previously in this section.
The best way to maintain skin integrity and to prevent skin breakdown is to prevent them from occurring in the first place. Some of these preventive techniques include:
The screening of all clients for their potential for skin breakdown and then initiating special preventive measures Performing skin assessments and reassessments on a regular basis Keeping the client clean and dry at all times to prevent moisture and skin maceration as well as debris Turning and positioning clients at least every two hours when the client is unable to move about in bed to turn and position on their own Maintaining the client''s body and bodily parts
The Braden Scale for Predicting Pressure Ulcers and the Norton Pressure Ulcer Scale are two of the most popular standardized screening tools that are used to screen and assess clients in order to determine if they are at risk for skin breakdown. Both of for 1 last update 2020/06/04 these standardized screening tools are deemed valid and reliable for identifying those at risk.The Braden Scale for Predicting Pressure Ulcers and the Norton Pressure Ulcer Scale are two of the most popular standardized screening tools that are used to screen and assess clients in order to determine if they are at risk for skin breakdown. Both of these standardized screening tools are deemed valid and reliable for identifying those at risk.
Pressure ulcers are also referred to as stasis ulcers, trophic ulcers, and ischemic ulcers; they can result from the mechanic forces of pressure, friction and shearing, all of which can, and should, be prevented.
Pressure, particularly over boney prominences, areas of poor tissue perfusion, and areas affected with poor circulation, is a physical force associated with the development of pressure ulcers and skin breakdown. Pressure occludes the vessels that oxygenate the area and it also causes cellular damage because harmful substances, such as toxins, accumulate in the area where the pressure is exerted.
Pressure can be eliminated and reduced with out of bed activity, pressure relieving surfaces, the provision of sitting and lying surfaces free of any objects and wrinkles, and by turning and repositioning clients frequently to prevent this damaging mechanic force.
Friction occurs when a person''s skin and its underlying tissues. Shearing can be prevented by elevating the head of the bed no more than 30 degrees unless contraindicated, using a lift or a lifting team, if you have one, by transferring clients carefully, getting help when turning and positioning a client, getting as much client cooperation as possible during turning, positioning and transfers, using a pressure relieving bed, and lubricating the skin with a lubricating moisturizer to prevent the damaging skin effects associated with pressure, friction and shearing. Corn starch is NOT used.
Pressure ulcers are costly both in terms of health care costs and the human costs that the client suffers as the result of a pressure ulcer including, but not limited to, pain, sepsis, cellulitis, and osteomyelitis. When pressure ulcers are not prevented, the nurse must assess and care for it. Pressure ulcers are staged from the least severe to the most severe from Stage 1 to Stage 5. These stages are:
Stage I: The skin remains unbroken and intact. The skin among those with a light skin tone may have some redness or blanching of the affected area; and those with darker skin tones may have a blue, purple or ashen tinge to the affected area. Additionally, all clients may have some sensitivity and burning, coolness or increased warmth to the affected area. Stage II: The closed and intact skin is now open. The epidermis and the dermis are damaged. The wound may appear as a blister, crack or a wound that is pink in color. Stage III: The wound is now considered a deep wound; the subcutaneous tissue and all the layers of the skin, including the epidermis and dermis and even adipose tissue may be exposed and affected. The wound has a blood tinged drainage as well as dark areas and yellow colored area of dead and necrotic tissue, referred to as eschar and slough, respectively, appear. Stage IV: The deep pressure ulcer extends to underlying areas including the muscle, fascia, connective tissue, tendons, and even the bone under the skin and subcutaneous tissue. Signs of necrotic tissue including eschar and slough are evident.
The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. RYB stands for the colors of red, yellow and black. The rules of treatment for these three colors are:
Red: Protect the area. A new reddened area is protected from further harm and damage with interventions such as turning and positioning the client, keeping the client''s use of its own enzymes to debride the wound. This process is referred to as autolysis. Autolytic debridement is most often used to treat Stage 3 and Stage 4 pressure ulcers.
The procedure for autolytic debridement entails the use of a semi-occlusive, occlusive, hydrocolloid, alginate, or hydrogel treatment and a transparent dressing to keep the area moist while the body uses its own enzymes like its fibrinolytic, proteolytic, and collagenolytic enzymes, as well as its on white blood cells to debride a wound and remove its eschar and slough.
The advantages of this kind of wound debridement include its effectiveness, its ease in terms of performing it, its relative safety, and lack of for 1 last update 2020/06/04 pain for the client. Some of its disadvantages, however, include the fact that autolytic debridement is not as rapid as a surgical debridement in terms of its effectiveness and the fact that anerobic microbes may thrive under the dressing that is used for this type of debridement.The advantages of this kind of wound debridement include its effectiveness, its ease in terms of performing it, its relative safety, and lack of pain for the client. Some of its disadvantages, however, include the fact that autolytic debridement is not as rapid as a surgical debridement in terms of its effectiveness and the fact that anerobic microbes may thrive under the dressing that is used for this type of debridement.
Enzymatic Chemical Debridement
Enzymatic for 1 last update 2020/06/04 chemical debridement can be used on wounds with at least moderate amounts of necrosis and eschar, including pressure ulcers and burns.Enzymatic chemical debridement can be used on wounds with at least moderate amounts of necrosis and eschar, including pressure ulcers and burns.
The enzymes introduced for this type of debridement are maintained within a moist environment so that they can destroy cellular debris, slough and eschar. The eschar is gently crosshatched with a scalpel so that the introduced enzymes can penetrate all layers of it.
Some of the advantages associated with chemical debridement include its relatively rapid, action and its ability to be selective and not damage healthy surrounding tissue. Some of its disadvantages include local irritation, its relatively high cost, and the need for frequent dressing changes once or twice a day.
Sharp Instrument Debridement
This method of debridement entails the removal of necrotic tissue using a scalpel, forceps and scissors by the doctor. This method is the most rapid of all debridement methods but it can lead to client pain and discomfort.
Topical the 1 last update 2020/06/04 antibiotics that are often used to treat wounds, as based on the identified offending microorganism, include, among others:Topical antibiotics that are often used to treat wounds, as based on the identified offending microorganism, include, among others:
Cadexomer iodine Gentamicin Metroidazole Mupirocin Polymyxin B sulphate Silver sulfadiazine Applying a Knowledge of Nursing Procedures and Psychomotor Skills When Providing Care to Clients with Immobility
Nursing care consists of all of the phases of the nursing process including assessment, nursing diagnosis, planning implementation and evaluation.
In terms of assessment, the nurse assesses and reassess the client for actual and potential complications of immobility as fully discussed above under the section entitled ""https://www.registerednursing.org/nclex/mobility-immobility/#identifying-complications-immobility"" and the clients''s mobility were also discussed above in these same sections.
Planning is done according to the actual and potential health problems that were assessed and then expected for 1 last update 2020/06/04 client outcomes or goals and interventions are planned to meet these needs. Some of the expected client outcomes relating to immobility and mobility can include specific goals such as:Planning is done according to the actual and potential health problems that were assessed and then expected client outcomes or goals and interventions are planned to meet these needs. Some of the expected client outcomes relating to immobility and mobility can include specific goals such as:
The client will perform active range of motion to all joints two times a day The client will safely transfer from the bed to the chair with assistance The client will be free of venous stasis The client will demonstrate proper deep breathing and coughing The client will ambulate 30 feet three times a day with a walker and the assistance of another The client will increase their level of exercise and physical activity The client will demonstrate the proper use of their assistive device The client will maintain skin integrity The client will maintain adequate respiratory functioning
The interventions for immobility according to system that can be adversely affected with immobility, in addition to the constant monitoring of the client, assessments and reassessments for these hazards, include:
Urinary System: Maintain adequate fluid intake, measure, document and monitor the client''s airway which can result from immobility and some respiratory diseases and disorders.
Postural drainage, percussion and vibration are often referred to as pulmonary hygiene measures and pulmonary physiotherapy measures. Coughing, deep breathing and the use of an incentive spirometer are described as hyperinflation exercises because, when done properly, these respiratory techniques hyper inflate the lung to facilitate the loosening and mobilization of respiratory secretions. All of these measures are used not only for immobilized clients but also for many post-operative clients.
The procedure for deep breathing and coughing is as below. The client should be coached and taught to:
Splint any painful or tender abdominal areas with a pillow or the client''s position or sitting in the chair, the client is instructed to put the mouth piece tightly into their mouth and to take the deepest possible diaphragmatic breath while observing the ball rise to the level of their goal. The client should be reminded and encourage to take at least 10 breaths using the incentive spirometer at least every 2 hours while they are awake.
Postural drainage is done by the nurse or the certified respiratory therapist. This technique entails the positioning of the client in different positions so that all areas of the lungs and airways are able to be drained of respiratory secretions using the force of gravity. For example, the client is positioned prone and in a 45 degree Trendelenburg position to drain the posterior bronchus, a 45 degree Trendelenburg position to drain the posterior bronchus and on the left side to drain the lateral bronchus.
Percussion is also performed by the nurse or the certified respiratory therapist. This technique entails the placing a cupped hand over the lung areas and doing gentle tapping on the area for about one minute while the client is hyper inflating their lungs and holding the breath as long as possible. The client is placed in the same positions that are used for postural drainage, as discussed immediately above. In fact, percussion is most often done in combination with postural drainage.
Vibration is highly similar to percussion except vibration is done by placing the palm of the hand on the lung area and doing rapid vibrating movements on the area while the client is positioned for postural drainage.
Inspiratory muscle training techniques entail instructing the client to lie in a comfortable supine position, to relax, and then to take deep breaths with a mouth piece with an increasingly smaller lumen so that the client has to progressively take deeper and deeper breaths using their diaphragm while overcoming the resistance of the obstructive mouth piece.
Applying, Maintaining and Removing Orthopedic for 1 last update 2020/06/04 DevicesApplying, Maintaining and Removing Orthopedic Devices
DIY Bunker Boxhow to DIY Bunker Box for Some of the orthopedic devices that nurses apply, maintain and remove include traction devices, splints, braces and casts:
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DIY Bunker Boxhow to DIY Bunker Box for Traction, simply defined, is a physical pulling force that exerts pulling on the bodily part. Traction is used for the external fixation of a fracture, it is used to maintain anatomically correct alignment, it is used to reduce pain and it is used to decrease muscle spasms.
Traction forces are classified and categorized as Inline or running traction and balanced traction. Balanced traction utilizes the weight of the client''s skin traction, exerts the traction force along the long axis of the bone and along one plane.
The three basic traction techniques can also be classified as manual traction, skeletal traction and skin traction. Manual traction, which is applied with the hands, is done to properly align a bone after a fracture so that a cast can be applied to the bone while it is in correct anatomical alignment. Skeletal traction is applied directly to an affected bone with a continuous traction force and with the use of a surgically inserted Steinman pin that is placed into the distal end of the affected bone.
Lastly, skin traction applies the traction force to the skin overlying the affected bone. The purpose of skin traction is to decrease pain and muscular spasms after a fracture has been surgically repaired with internal fixation. Skin traction is the most commonly used type of traction.
The externally placed skin traction must be applied firmly but without any potentially damaging pressure and in a smooth manner without any creases. The weights are gently applied, as ordered, and left to hang freely and without any interference. The skin underneath skin traction must be inspected on a regular and ongoing basis to prevent some of the possible complications associated with this type of traction including blistering, skin breakdown, compartment syndrome, circulatory impairment, neurological impairment, and areas of necrosis. Also, the skin around the surgical site for skeletal traction must also be inspected for any signs of infection.
DIY Bunker Boxhow to DIY Bunker Box for The primary purposes of splinting for limb fractures are to protect soft tissue from further damage, to reduce the client''s ordered analgesic medications. The later signs of compartment syndrome include burning pain secondary to ischemia, paresthesia secondary to neurological impairment, hypoesthesia secondary to sensory nerve damage, pulselessness, and cool and pale skin.
Compartment syndrome is a medical emergency which, left untreated, can lead to the loss of the affected limb. The treatment plan includes the removal of the cast and, at times, a fasciotomy or epimysiotomy are indicated.
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Compression stockings, or antiembolism stockings or hose, and automatic sequential compression devices are used to promote venous return and prevent emboli, both of which can occur as the result of patient immobilization and other causes such as deep vein thrombosis. At times, these devices are routinely ordered for post-operative clients to promote venous return. These devices are ordered by the doctor in terms of millimeters of mercury that they will apply to the lower extremities.
DIY Bunker Boxhow to DIY Bunker Box for At the current time, automatic sequential compression devices are used in health care facilities and they have virtually replaced the use of compression hose; however, compression stockings continue to be used in other areas including the client''s legs and checking the doctor''s leg. Some of these compression stockings are knee high and others are thigh high. These stockings are gently and smoothly pulled over the client''s measurements and they come in both thigh high and knee high sleeves. Unlike compression hose that exerts continuous pressure on the lower extremities, automatic sequential compression devices deliver intermittent pressure at the ordered pressure and as set on the pump.
DIY Bunker Boxhow to DIY Bunker Box for These sleeves, like compression hose, require that the nurse regularly check them to insure that they remain in place and they, too, should also be removed at least one time a day so that the nurse can inspect the skin underneath it and also to check the skin for its color and warmth.
Educating the Client Regarding the Proper Methods Used When Repositioning an Immobilized Client
Clients should be educated about the proper methods that will be used to position and reposition them in bed while they are immobilized. Some of the elements of this teaching should include:
The rationale for the need for frequent position changes The different positions that they will be used The devices, such as pillows and bolsters, that will be used to maintain the position and proper bodily alignment Ways that the client can assist with position changes. For example, the client may be encouraged to bend their knees and then exert pressure on their heels as they are being moved up in bed. The rationale for maintaining an angle of no more than 30 degrees to prevent skin breakdown Signs and symptoms like a burning or sore feeling on a bodily part that must be reported to the nurse The purpose of and the procedure for a mechanical lift if the client will be using one The purpose of the lifting team if the facility has one DIY Bunker Boxhow to DIY Bunker Box for Maintaining the Client''s position, the dorsal recumbent position, the prone position and the lateral position.
The lateral position is a side lying position with the upper most knee bent and often maintained in that position with a pillow; the Fowler''s position is a semi prone position.
These positions are supported and maintained with pillow, bolsters and wedges when necessary to maintain anatomically correct bodily alignment.
Maintaining and Correcting the Adjustment of the Client''s ordered traction. When applying traction, the client should be placed in the supine position and boney prominences should be protected from friction and shearing. Traction, when ordered, should be continuous and not interrupted.
The procedure for setting up traction is as follows:
Lubricate the pulleys with a silicone spray Add the precise weight that was ordered by the doctor Apply and maintain the weights so that they hang freely. They should never touch the floor or any other surface such as a part of the bed because this will interfere with the traction''s body, the client will slide to the source of the traction. The nurse should tilt the bed when this occurs and this can be prevented by keeping the client''s circulatory function in addition to preventing complications of immobility such as muscular weakness and venous stasis. When mobilization and ambulation are impaired as the result of muscular weakness and/or impairments of their gait, balance and coordination, the client should be provided with rehabilitation and restorative care to facilitate this mobilization and ambulation. Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown
As previously discussed skin integrity can be maintained and skin breakdown can be prevented with a number of different interventions such as turning and repositioning the client at least every two hours, special pressure relieving mattresses, and the avoidance of all pressure, friction and shearing.
Evaluating the Client''s expected outcomes were accomplished after preventive measures were implemented to prevent the complications associated with immobility. For example, the nurse will determine whether or the client is able to: Perform active range of motion to all joints two times a day Safely transfer from the bed to the chair with assistance Be free of venous stasis Demonstrate proper deep breathing and coughing Ambulate 30 feet three times a day with a walker and the assistance of another Increase their level of exercise and physical activity Demonstrate the proper use of their assistive device while ambulating Maintain their skin integrity and not have any signs of skin breakdown Maintain adequate respiratory functioning
RELATED the 1 last update 2020/06/04 CONTENT: RELATED CONTENT:
SEE - Basic Care & Comfort Practice Test Questions
Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.
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