Fundamentals of Nursing Care Concepts Connections Skills Second

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Chapter 16 Moving and Positioning Patients Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terminology Related to Movement § Contractures § Shortening and tightening of muscles due to disuse § Dorsiflexion § Bending of the foot in an upward direction § Plantar flexion § Bending of the foot in a downward direction Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terminology Related to Positioning Patients § Log roll § Patient is turned in the same way a log would be rolled (as one unit) § Trochanter roll § Tightly rolled sheet or blanket placed against the lateral side of the thigh to prevent outward motion of the hip and leg Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Hazards of Immobility § § Blood clots Pneumonia Bone demineralization Kidney stones Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Hazards of Immobility (cont. ) § § Constipation Pressure ulcers Urinary retention Depression Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Body Systems Affected by Immobility § § § § Musculoskeletal Cardiovascular Respiratory Gastrointestinal Urinary Integumentary Neurological Psychological effects Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Preventing Musculoskeletal Complications § Maintain proper body alignment § Keep the head, trunk, and hips in a straight line § Prevent the legs from rotating in the hip socket medially or laterally § Maintain arms in correct alignment with the shoulders Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nursing Actions to Prevent Contractures and Osteoporosis § Perform ROM exercises every 8 hours § Support the weight of the extremity at the joints § Apply any supportive or therapeutic devices for maintaining body alignment § Assist with ambulation as soon as orders permit Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Effects of Immobility on the Cardiovascular System § Venous thromboembolism (VTE) § Orthostatic hypotension § Syncope Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nursing Measures to Prevent Cardiovascular Complications § Encourage the movement of extremities § Apply ordered devices to prevent pooling of blood in the legs § Gradually move the patient from lying to sitting or to a standing position § Change the patient’s position frequently § Remain with the patient the first few times getting out of bed and dangling Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nursing Measures to Prevent Respiratory Complications § § Turn the patient from side to side every 2 hours Elevate the head of the bed 45 degrees Encourage coughing and deep breathing Encourage use of the incentive spirometer Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nursing Measures to Prevent Gastrointestinal Complications § Assist the patient with early ambulation § Reposition the patient every 2 hours; encourage ROM exercises § Place the patient in a sitting position on the bedpan § Inquire about food likes and dislikes and plan balanced meals § Encourage fiber and fluid intake § Administer a laxative or stool softener PRN Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nursing Measures to Prevent Urinary Complications § Encourage fluids to prevent concentrated urine § Assist female patients to urinate in a sitting position § Assess the patient’s output Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nursing Measures to Prevent Integumentary Complications § Provide adequate nutrition § Reposition the patient every 2 hours § Inspect bony prominences for redness every 2 hours and massage the area around the redness § Use mild soaps for cleansing skin § Provide an appropriate surface for the patient Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nursing Measures to Prevent Neurological Complications § Determine the patient’s level of consciousness by asking specific questions relating to person, place, and time § Use a footboard to keep feet in a natural position § Perform neurological checks § Provide clues in the room to the correct date and time Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition § § § § Psychological Effects of Immobility Depression Anxiety Hostility Fear Isolation Restriction of self-image and independence Sensory deprivation Difficulty sleeping Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nursing Measures to Prevent Psychological Complications § Minimize sensory deprivation § Involve patient senses when with the patient § Encourage the patient to remain awake during the day and do as much for the self as possible § Allow the patient to express concerns § Encourage visits from family and friends Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Position of Function § Places the extremities in alignment § Maintains the potential for their use and movement § Helps prevent undue pressure on the nerves § Helps prevent discomfort, pain, and nerve damage § Uses devices including pillows, hand rolls, arm boards, and foot boards Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Common Patient Positions § Supine: Lying on back, arms at side § Dorsal recumbent : Lying on back, arms at sides, legs apart, knees bent, feet flat § Trendelenburg : Lying on back, arms at side, feet higher than head § Reverse Trendelenburg : Lying on back, arms at side, head higher than feet § Lateral: Lying on back or right side, supported by pillows Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Common Patient Positions (cont. ) § Left Sims: Left side semi-prone, right leg drawn up to chest, left arm along patient back § Right Sims: Right side semi-prone, left leg drawn to chest, right arm along patient back § Low, semi-, and high Fowler’s: Semi-sitting with various degrees of head elevations § Orthopneic : Sitting upright, leaning slightly forward, arms supported on overbed § Prone: On stomach with head to side § Lithotomy: On back, legs in stirrups Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition ANA Handle With Care® Campaign § Instituted in response to significant number of musculoskeletal disorders reported by nurses § “No lifting” programs; instead, use lift equipment § Sit-to-stand lifts, hydraulic lifts, battery-powered lifts Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Devices Used to Move Patients § § § Transfer belts Nylon friction reducing devices Slide boards Partial or full weight-bearing assist devices Overhead ceiling lift devices Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Support Surfaces and Specialty Beds § Mattress overlays § Specialized mattresses § Specialty beds § § Air-fluidized bed Low air-loss bed Combination air-fluidized and low air-loss bed Continuous lateral-rotation bed Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information in the Connection Features § § § § Clinical Connection Knowledge Anatomy and Physiology Patient Teaching Real World Supervision/Delegation Post Conference Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information in the Safety Features § Why are the particular safety features so important that they are highlighted as safety issues? § What could happen if those safety guidelines are not followed? Copyright F. A. Davis © 2015

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information in the Skills Procedures § Review the steps of each of the skills procedures. § Make sure you understand why the steps are important. § What could happen if each of the steps are not followed or are followed out of order? Copyright F. A. Davis © 2015