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
Make a bed
Administer personal care and apply restraintsObjectives
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
Cells die, skin breaks down and open sore (ulcer) develops
EASIER TO PREVENT THAN TO TREATDecubitus Ulcer Cont.
Prompt cleaning of urine and feces from skin
Massage in circular motion around reddened area
Light dusting of powder to prevent friction
Frequent turning and positioning…q 2h
Linen dry and free from wrinkles
Use of pressure-relieving surfacesPrevent Decubitus Ulcers by:
Carefully observe the skin during bathing for evidence of pressure sores
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
Lower the head of the bed immediate supervisor
Place the pillow against the bed frame to protect the pts. Head
If pt. has trouble breathing, raise the head of the bed
Ask the pt. to flex the knees and brace the feet on bed / pushing heels into the bed to assistMoving the Pt. Up in Bed
Place one arm under the pts. Head and shoulders immediate supervisor
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.
Observe correct body mechanics discomfort and lead to decubitus ulcers
Keep linen arranged in the order of use
Make one side of the bed completely, then on the other side
Roll dirty linens away from your body and place in hamper immediatelyBedmaking Tips
Do not shake clean or dirty linen. discomfort and lead to decubitus ulcers
Place open end of the pillowcase away form the door
Wear gloves while handling dirty or contaminated linen
Involves tooth brushing and flossing discomfort and lead to decubitus ulcers
Should be done at least three times a day
Provide necessary equipment such as toothbrush, toothpaste, dental floss, mouthwash, emesis basin, cup, and water
Assist the patient as neededRoutine Oral Hygiene
Usually require a physician’s order discomfort and lead to decubitus ulcers
Make sure tub or shower is clean
Put rubber mat in tub or shower
Full tubs half full with water at 105 F
Help pt. into the tub or shower (Use the shower chair for pt. who cannot stand)
Assist pt. as neededTub Baths and Showers
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.
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?
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?
Put over bed table in position the following:
Check to make sure the pt. is not NPO
Make sure the diet is correct for the pt.
Place a towel or napkin under pts. chin
Open packages and cartons; season and cut foods if necessaryFeeding Cont.
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.
Allow pt. to help as much as they are able to
Offer choices to the pt.
Wipe the pts. mouth as necessary
Encourage pt. to each as much as possibleSteps for Feeding Pts. Cont.
Provide oral hygiene
Position pt. in correct body alignment
Note how much food was eaten
Calculate I & O if this is ordered for pt.After the Meal
Place call bell and tissue within the pts. reach
Raise siderail before leaving the pt.Assisting with a Bedpan cont.
Provide privacy for pt.
Assist with placement of the urinal if needed
Leave the call bell and toilet tissues near the patient
Answer the pts. call bell immediatelyAssisting with Urinal
Have pt. hand you the urinal if they are able
Close the lid or cover the top of urinal
Assist pt. with washing hands
Assist pt. with washing perineum if needed
Measure contents of pts. I & O
Empty urinal and clean
Report abnormalities related to urineAll finished
Restraint applied unnecessarily=false imprisonment
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
Loss of muscle tone
Respiratory or breathing problemsComplications from Restraints