Position, Turn, and Transfer patients Make a bed Administer personal care and apply

restraints

Must use correct body mechanics

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 contractures

Pressure sore or bed sore

Caused by pressure that interferes with circulation

Usually at bony prominences – coccyx, hips, knees, heels, and elbows

First sign is a pale or reddened area on the skin

Vesicle or blister may for at the site

Cells die, skin breaks down and open sore (ulcer) develops

EASIER TO PREVENT THAN TO TREAT

Good skin care 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 surfaces

Carefully observe the skin during bathing for evidence of pressure sores

Tightening or shortening of muscle due to lack of movement or usage

Foot drop common contracture Prevented by keeping foot at right angle

to leg ROM will help prevent contractures

Weakened body parts must be supported with pillows, bed cradles, footboards, rolled blankets or towels

Pt must be turned frequently

Dangling Sitting on side of bed prior to standing Allows patient time to adjust If the patient c/o vertigo, weakness or

diaphoresis – return pt. Immediately to supine position

Mechanical Lifts Used to transfer weak or paralyzed patients Be sure you have been instructed on proper

use Reassure patient during transfer

Transferring Be sure to protect patient and health

care worker Be sure you know how to operate the

wheelchair/stretcher FIRST Lock the wheels

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 supervisor

Lower the head of the bed 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 assist

Place one arm under the pts. Head and shoulders

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

Lower the side rail nearest you – be sure the opposite side is up

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 you

Place both hands under the legs and slide the legs toward you

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 bed

Linen must be free of wrinkles as they could cause discomfort and lead to decubitus ulcers

Closed Bed Made after the pt. is discharged and after

terminal cleaning of unit Purpose: keep bed clean until new pt. comes

Open Bed Fanfold top sheets to welcome new pt. or for

ambulatory pts.

Occupied Bed Bed made while pt. is in it

Bed with Cradle Cradle is placed under top sheets to

prevent linen from touching parts of the pts. Body. Used for pts. With burns, skin ulcer, blood clots, fractures, and other similar conditions

Observe correct body mechanics 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 immediately

Do not shake clean or dirty linen. Place open end of the pillowcase away

form the door Wear gloves while handling dirty or

contaminated linen

Benefits: Provides comfort Stimulates the appetite Prevents disease and dental caries Helps to prevent bad breath (halitosis) Stimulates saliva production which

contains digestive enzymes and promotes digestion

Involves tooth brushing and flossing 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 needed

Proved privacy for the pt. Have pt. remove dentures if able Place dentures in a denture cup to carry to

sink Use warm water to clean dentures…hold

over emesis basin lined with paper towels to prevent them breaking if you drop them

Hold dentures securely. Let pt rinse mouth and brush gums

Store dentures in a denture cup labeled with the pts. Name

Usually given to unconscious or semiconscious pts

Tell the pt. what you are doing Turn pt to their side Turn pts head toward you Use a very small amt. of liquid Clan all areas of mouth:

Teeth, Gums, Tongue, Roof of Mouth Apply lubricant to tongue and lips

Types of Baths Complete Bed Bath (CBB)

Pt. is usually confined to bed and the health care worker must bathe all parts of the pts. body

Partial Bed Bath Pt. washes some of the parts of their body and

the health care worker washes the parts of the body the pt. cannot reach

Tub Bath or Shower Health care worker prepares the tub or shower area and assists pt. as needed

Cleans tub once bath is over and pt is back in their bed or chair

Use standard precautions

Provide privacy, comfort, and safety

Fill basin 2/3 full with warm water at a temp. of 105-110 F

Form a mitten around your hand with the cloth to keep from hitting pt during bath

Wash body parts in this order: Face, ears, and neck -> axilla, arms, and

hands (apply deodorant) -> chest, breast, and abdomen -> thighs, legs, and feet (change water) -> back, buttock, and back of perineum (give back rub) -> perineum area

Change water when it becomes too cool, dirty or soapy

Usually require a physician’s order 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 needed

Stay with pt. or make sure pt. can use the emergency call system

After bath or shower, cover pt. with a towel or bath blanket

Clean the tub or shower with a disinfectant after each use

Amount of fluid taken into the body should equal the amount of fluid lost from the body.

Excessive fluid retained by body = edema

What do you measure?Intake OutputOral BowelIV EmesisIrrigation Urine

Irrigation

Oral Includes liquids taken by mouth Also includes foods that are liquid at

room temp. such as soup, jell-o, ice cream, pudding, and Popsicle’s

Tube feeding is usually recorded under oral intake

Fluids are measured in metric units – cc/ml

1 Cubic Centimeters (cc) = 1 Millimeter (ml)

Memorize these equivalents 1 ml or cc =15gtts (drops) 5ml or cc = 1 tsp (teaspoon) 15 ml or cc = 1 tbsp (tablespoon) 30 ml or cc = 1 (oz) ounce 240 ml or cc = 1 cup (8 oz) 500 ml or cc = 1 pint (16 oz) 1000 ml or cc = 1 quart (32 oz)

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? 580

Output = all fluids eliminated by the pt. BM

Liquids BMs are measured and recorded Solid or formed BM is usually noted under

feces or the remarks column Emesis

Measure anything that is vomited Also not color, type, and other facts in the

remarks column

Urine Measure all urine voided or drained via a

catheter Men can collect their urine in a urinal and

women can collect their urine in a bedpan or a special urine collector that can be placed under the seat of the toilet

Irrigation Measure any drainage from nasogastric tubes,

hemo-vacs, chest tubes or other drainage tubes These measurements are usually done by the

nurse

Jennifer is on I & O. A the end of an 8 hour shift, you note the following:

0800 she voided 400 cc of urine1000 she vomited 200 cc of thick yellow

emesis with food particles in it1130 she had one formed green BM1315 she voided 350 cc of urine

What was Jennifer’s output for the 7-3 shift?

950

Prior to meal: Provide privacy Help pt. use the bedpan or urinal if needed Provide oral hygiene if desired Remove emesis basins or bedpans for sight Position pt. in a sitting position if allowed Wash pts. hands and face

Put over bed table in position 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 necessary

Test temperature of hot foods by placing small amount on wrist

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 bites

Alternate the foods and liquids 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

possible

Allow pt. to wash their face and hands Provide oral hygiene Position pt. in correct body alignment Clean area Note how much food was eaten Calculate I & O if this is ordered for pt.

Urinate, micturate, or void – terms for emptying of the bladder, which stores urine Urinals are used by male pts. when they need

to micturate A bedpan is used by females when they need

to micturate Defecate – having a bowel movement

Both men and women must use a bedpan when they need to defecate

Two main types of bedpans Fracture or orthopedic bedpan Standard bedpan

Many patients are sensitive about using the bedpan. Always provide privacy and make them as comfortable as possible.

Use standard precautions and wear gloves

Provide privacy for the pt Warm bedpan by running warm water

over it There are two positions to place the pan

under the pt. Pt. flexes knees and puts weight on heels.

They then lift their hips up Pt. is turned to one side and the pan is placed

against the buttock and the pt is rolled back on the pan

The pts. buttocks should rest on the rounded portion of the pan

Place call bell and tissue within the pts. reach

Raise siderail before leaving the pt.

Answer call bell immediately Use the same positions to get pt. off

the pan, but hold pan firmly Cover the bedpan and place on nearby

chair or table Make sure perineum is clean and dry Assist pt. in washing hands Clean bedpan and note any

abnormalities of urine or BM

Use standard precautions and wear gloves

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 immediately

Avoid exposing the pt. 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 urine

May be used only to protect pts. from harming themselves or others

Must have doctor’s order to use restraints

Conditions that may require restraints Irrational or confused pts. Skin conditions Paralysis or limited muscular conditions

Types of restraints Straps or safety belts Limb restraints Leather Cuffs or locks Restraint jackets

Restraint applied unnecessarily=false imprisonment

Use only when other alternatives fail 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 given

Physical and mental frustration Impaired circulation Decubitus ulcers Loss of muscle tone Joint stiffness Respiratory or breathing problems