Patients who have quadriplegia are at an increased risk for skin breakdown, especially over the bony prominences and in the sacral area, due to impaired mobility, infrequent repositioning, and skin exposure to such irritants as rough linen, urine, and stool. Any of these conditions may result in tissue damage from impaired circulation or skin breakdown. Since the patient has quadriplegia, he may also be unable to report the first signs of skin breakdown because of impaired or absent sensation. It was reported to you that the patient had sacral redness when last turned 2 hours ago so not only is the patient due to be turned again now, but your immediate nursing assessment of the sacral area is your highest priority at this time.
The height of a properly fitted walker should be just below the level of the patient’s waist. The patient should stand in the center of the walker and grasp the handgrips on either side, with her elbows bent approximately 30 degrees.
Patients who need total care also require a thorough nursing assessment. Not only are they at increased risk for skin breakdown due to impaired mobility, but they are also at increased risk for other complications of immobility, including respiratory failure, impaired circulation, and sluggish digestion. It can be helpful to use the nursing process when deciding the order of nursing actions, Assessment is first, and it guides your subsequent actions. Also, performing the morning assessment while providing hygiene care is an efficient use of your nursing time.
Passive ROM exercises are performed without the patient’s assistance to prevent joint contracture. These are most appropriate for a patient who is totally dependent and unable to follow instructions.
The sling (or hammock) is supplied with the lift. Hammocks that provide neck support are best for patients who are flaccid or have poor muscle tone. This helps ensure the patient’s safety.
Using this method, the slide board remains stationary as two team members pull the draw sheet and move the patient. This slippery surface reduces friction and makes it easier for the staff to pull the patient onto the gurney.
When responding therapeutically to patients’ questions, always remember that you must use communication skills and avoid communication blocks. In general, therapeutic responses are open-ended, patient-centered, and focused on the patient’s feelings. This response meets all of these criteria. By acknowledging that you have heard the patient’s message, this response encourages further communication.
Dangling allows the patient’s circulation to equilibrate and helps prevent episodes of dizziness due to orthostatic hypotension and, therefore, injuries from falling.
-Administer the prescribed oral pain medication to your patient about 20 minutes before she gets out of bed.
Oral pain medication typically has a time of onset of about 20 minutes, so the patient will have the benefit of pain relief while moving – the most difficult and painful aspect of getting up
-Teaching and demonstrating the techniques to be used enhance the patient’s understanding, reduce anxiety, and encourage her to cooperate with the procedure.
Flexing the hips and knees while lifting weight reflects good body mechanics as this prevents injury due to poor body alignment. Flexion of the knees and hips lowers your center of gravity in relation to the object you are raising or lifting.
These values are a reflection of the patient’s capacity to carry oxygen in the blood. This patient’s results are below the normal range, possibly as a result of blood loss during surgery. A hemoglobin and a hematocrit below normal indicate anemia, which causes the manifestations of extreme fatigue, pallor, and weakness.
This demonstrates full range of motion of the shoulder. The patient’s fingers would be pointing directly upward.
The bed should be raised to its highest position in order to prevent injury to nursing staff and to properly position the lift under the patient’s bed.
The crutches should be held on the unaffected side when preparing to sit in a chair.
is a correct strategy that helps the nurse safely stabilize the patient while moving to a standing position.
This maneuver, the Romberg test, assesses balance. The nurse watches for swaying and stands near the patient to protect him from falling.
As the patient gets close to the floor, the nurse bends both legs, continuing to support the patient.