Nursing Skills. Position, Turn, and Transfer patients Make a bed Administer personal care and apply restraints. Objectives. Must use correct body mechanics Alignment = Positioning body parts in relation to each other to maintain correct body posture
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Alignment = Positioning body parts in relation to each other to maintain correct body posture
Correct alignment helps pt. feel comfortable; prevents fatigue, Decubitus ulcers and contracturesPositioning, Turning, Moving and Transferring Patients
Weakened body parts must be supported with pillows, bed cradles, footboards, rolled blankets or towels
Pt must be turned frequentlyContractures Cont.
Before moving patient, obtain proper authorization from immediate supervisor
Watch the patient closely – pulse rate, respirations and color
Observe for weakness, dizziness, increased perspiration or discomfort
If you note abnormal changes, return the patient to a safe and comfortable position and notify your supervisorWhen turning and Transferring
If the patient is unable to help, get someone to assist you
Get a broad base of support and as close to the bed as possible
Arrange a signal – “On the count of three, push with your feet”
On the signal, shift your weight forward
Two people can use a draw sheet or lift sheet
If the pt. is lying in the center of the bed, place hands under the pts head and shoulders and slide the pt toward you
Place both hands under the hips and slide the hips toward youTurning the Pt.
Cross the pts. arms across his/her chest
Move the leg closest to you over the other leg
Get close to the pt. and roll the pt. away from you
Explain what you are doing to the pt.
Place your hands under the head and shoulders, then the hips, drawing the pt. to the center of the bedTurning the Pt. Cont.
Linen must be free of wrinkles as they could cause discomfort and lead to decubitus ulcers
Place open end of the pillowcase away form the door
Wear gloves while handling dirty or contaminated linen
After bath or shower, cover pt. with a towel or bath blanket
Clean the tub or shower with a disinfectant after each useTub Baths and Showers Cont.
Amount of fluid taken into the body should equal the amount of fluid lost from the body.
IrrigationMeasuring and Recording Intake and Output
Fred is on I & O. When you go into his room after lunch, you examine his lunch tray and find he consumed the following:
1 hamburger, ½ bowl of chicken broth (1 soup bowl=200cc), 4 soda crackers, 1 cup of tea, ¾ carton of milk (1carton=8 oz), ½ bowl of jello (1 small bowl=120cc)
What was Fred’s fluid intake?Measuring Intake
Jennifer is on I & O. A the end of an 8 hour shift, you note the following:
0800 she voided 400 cc of urine
1000 she vomited 200 cc of thick yellow emesis with food particles in it
1130 she had one formed green BM
1315 she voided 350 cc of urine
What was Jennifer’s output for the 7-3 shift?Measuring Output
Feed pt. slowly and allow them time to chew
Use separate straw for each liquid
Hold utensil at a 90 degree angle to the pt. mouth
Give small bitesSteps for feeding pt.
Urinate, micturate, or void – terms for emptying of the bladder, which stores urine
Place call bell and tissue within the pts. reach
Raise siderail before leaving the pt.Assisting with a Bedpan cont.
Allow pt. to move as much as possible
Always tell pt. why they are being restrained
Reassure pt. frequently
Check circulation below limb restraints every 15 minutes
All restraints must be removed every 2 hours, condition of skin documented and skin care givenWhen using restraints