CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
1. Appropriate nursing actions: Nicole
a) When a client falls
• 1st priority – check on patient for any
injuries before that, guide the patient
to the floor.
b) Positioning to reduce injury for bony prominences
• Place pillows under areas and elevate
• Changes position for 2hrs
Elevate calves to protect
heels
c) Reducing shear injury (med surg pg 447)
• Avoid pulling and sliding patient against bed
• Keep head of bed at a slight elevation
• Make sure sheets and blankets have ripples in them that rub against
the patient’s skin
• Use others to assist to protect from shearing.
d) Reduce urinary tract infection
• Proper cleaning of Perineum – front to back
e) Reducing pressure ulcers- factors that are contributors (med surg pg
448)
CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
,CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
Preventing Pressure Injuries Positioning
• Pad contact surfaces with foam, silicone gel, air pads, or other materials
with pressure- redistribution properties.
• Do not keep the head of the bed elevated above 30 degrees to prevent
shearing.
• Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or
her.
• When positioning a patient on his or her side, position at a 30-degree tilt.
• Re-position an immobile patient at a frequency consistent with assessed
needs.
• Do not place a rubber ring or donut under the patient's sacral area.
• When moving an immobile patient from a bed to another surface, use a
designated slide board well lubricated with talc or use a mechanical lift.
• Place pillows or foam wedges between two bony surfaces.
• Keep the patient's skin directly off plastic surfaces.
• Keep the patient's heels off the bed surface using bed pillow under
ankles or a heel- suspension device.
Nutrition
• Ensure a fluid intake between 2000 and 3000 mL/day.
• Help the patient maintain an adequate intake of protein and calories.
Skin Care
• Perform a daily inspection of the patient's entire skin
CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
,CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
• Document and report any manifestations of skin infection.
• Use moisturizers daily on dry skin and apply when skin is damp
• Keep moisture from prolonged contact with skin:
• Dry areas where two skin surfaces touch, such as the axillae and under the
breasts.
• Place absorbent pads under areas where perspiration collects.
• Use moisture barriers on skin areas where wound drainage or incontinence
occurs.
• Do not massage bony prominences.
• Humidify the room.
Skin Cleaning
• Clean the skin as soon as possible after soiling occurs and at routine intervals.
• Use a mild, heavily fatted soap or gentle commercial cleanser for
incontinence.
• Use tepid rather than hot water.
• In the perineal area, use a disposable cleaning cloth that contains a skin-
barrier agent.
• While cleaning, use the minimum scrubbing force necessary to remove soil.
• Gently pat rather than rub the skin dry.
• Do not use powders or talc directly on the perineum.
• After cleaning, apply a commercial skin barrier to areas in frequent contact
with urine or feces.
f) For vital signs out of range (i.e low oxygen saturation) (module 1 slide 56-
59)
CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
, CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
• Normal body temperature 96.4 to 99.5 (depending on the site)
• Respiration Rate – 12 to20 breaths per minute
• BP – 120/80 and below; anything higher is abnormal
• Pulse-Oximetry (saturation) – 94 to 100%
• Pulse – 60 to 100 BPM
g) Appropriate measures in taking an oral temperature (module 1 slides55)
h) Vital signs that can indicate post-surgical pain?
CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
1. Appropriate nursing actions: Nicole
a) When a client falls
• 1st priority – check on patient for any
injuries before that, guide the patient
to the floor.
b) Positioning to reduce injury for bony prominences
• Place pillows under areas and elevate
• Changes position for 2hrs
Elevate calves to protect
heels
c) Reducing shear injury (med surg pg 447)
• Avoid pulling and sliding patient against bed
• Keep head of bed at a slight elevation
• Make sure sheets and blankets have ripples in them that rub against
the patient’s skin
• Use others to assist to protect from shearing.
d) Reduce urinary tract infection
• Proper cleaning of Perineum – front to back
e) Reducing pressure ulcers- factors that are contributors (med surg pg
448)
CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
,CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
Preventing Pressure Injuries Positioning
• Pad contact surfaces with foam, silicone gel, air pads, or other materials
with pressure- redistribution properties.
• Do not keep the head of the bed elevated above 30 degrees to prevent
shearing.
• Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or
her.
• When positioning a patient on his or her side, position at a 30-degree tilt.
• Re-position an immobile patient at a frequency consistent with assessed
needs.
• Do not place a rubber ring or donut under the patient's sacral area.
• When moving an immobile patient from a bed to another surface, use a
designated slide board well lubricated with talc or use a mechanical lift.
• Place pillows or foam wedges between two bony surfaces.
• Keep the patient's skin directly off plastic surfaces.
• Keep the patient's heels off the bed surface using bed pillow under
ankles or a heel- suspension device.
Nutrition
• Ensure a fluid intake between 2000 and 3000 mL/day.
• Help the patient maintain an adequate intake of protein and calories.
Skin Care
• Perform a daily inspection of the patient's entire skin
CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
,CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
• Document and report any manifestations of skin infection.
• Use moisturizers daily on dry skin and apply when skin is damp
• Keep moisture from prolonged contact with skin:
• Dry areas where two skin surfaces touch, such as the axillae and under the
breasts.
• Place absorbent pads under areas where perspiration collects.
• Use moisture barriers on skin areas where wound drainage or incontinence
occurs.
• Do not massage bony prominences.
• Humidify the room.
Skin Cleaning
• Clean the skin as soon as possible after soiling occurs and at routine intervals.
• Use a mild, heavily fatted soap or gentle commercial cleanser for
incontinence.
• Use tepid rather than hot water.
• In the perineal area, use a disposable cleaning cloth that contains a skin-
barrier agent.
• While cleaning, use the minimum scrubbing force necessary to remove soil.
• Gently pat rather than rub the skin dry.
• Do not use powders or talc directly on the perineum.
• After cleaning, apply a commercial skin barrier to areas in frequent contact
with urine or feces.
f) For vital signs out of range (i.e low oxygen saturation) (module 1 slide 56-
59)
CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
, CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
• Normal body temperature 96.4 to 99.5 (depending on the site)
• Respiration Rate – 12 to20 breaths per minute
• BP – 120/80 and below; anything higher is abnormal
• Pulse-Oximetry (saturation) – 94 to 100%
• Pulse – 60 to 100 BPM
g) Appropriate measures in taking an oral temperature (module 1 slides55)
h) Vital signs that can indicate post-surgical pain?
CHAMBERLAIN COLLEGE OF NURSING NUR 2356
FINAL exam review latest update 2022 GUARANTEED
SUCCESS
