Nursing Documentation and Patient Handling

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Questions and Answers

What should be documented regarding the application of Montgomery straps?

The time it takes to apply the dressings

Only the patient's name and medical record number

The types of medications administered while dressing

The patient's response to dressing care and pain assessment (correct)

Which of the following is NOT a consideration when moving a patient up in bed?

The patient's body weight

The patient’s ability to understand directions

Any activity restrictions for the patient

The nutritional needs of the patient (correct)

What action should be taken if a caregiver needs to lift more than 35 pounds of a patient's weight?

Seek assistance from a colleague

Use only a friction-reducing sheet for lifting

Lift without the need for further assistance

Consider the patient fully dependent and use assistive devices (correct)

Which method is suggested to avoid injury while moving a patient in bed?

Confirm the patient’s readiness to assist before moving Signup and view all the answers

In the context of delegation, who can be assigned to move a patient up in bed?

Nursing assistive personnel or unlicensed assistive personnel Signup and view all the answers

Why is it important to document the wound description and drainage after applying dressing?

To provide data for treatment evaluation and future care planning Signup and view all the answers

What should be included in patient and family education regarding dressing care?

The importance of dressing changes and signs of infection Signup and view all the answers

How should documentation be approached after applying dressings to a wound?

Record the type of dressing and the skin protectant used Signup and view all the answers

What is the primary purpose of patient identification?

To confirm the procedure for the correct patient Signup and view all the answers

What is the benefit of using proper bed height during patient procedures?

It minimizes back strain for the caregiver Signup and view all the answers

What should be assessed to determine the need for additional caregivers during patient movement?

The patient's level of consciousness and ability to assist Signup and view all the answers

In what position should the bed be adjusted if the patient can tolerate it?

Slight Trendelenburg position Signup and view all the answers

Which piece of equipment is specifically mentioned as necessary for assisting with patient mobility?

Friction-reducing device Signup and view all the answers

Why is it recommended to remove pillows from under the patient except for one at the head?

To facilitate movement Signup and view all the answers

What is the primary goal of the nursing diagnosis during assessment?

Reduce the risk for injury and maintain proper body alignment Signup and view all the answers

What is the role of positioning nurses on either side of the bed?

To assist with patient movement and minimize strain Signup and view all the answers

What is the purpose of a friction-reducing sheet under the patient?

To reduce friction and support the patient's weight Signup and view all the answers

When should PPE be utilized according to the nursing protocols outlined?

Based on transmission precautions and assessment Signup and view all the answers

Which outcome is NOT included in the outcome identification and planning for patient movement?

Patient experiences increased pain during movement Signup and view all the answers

How can a patient assist with their own movement during a procedure?

By bending their legs and placing their feet flat on the bed Signup and view all the answers

What is a consequence of not positioning the patient's legs correctly?

Potential for skin shearing on the heels Signup and view all the answers

Why is it important to assess for tubes and IV lines before moving a patient?

To avoid disrupting treatment and causing injury Signup and view all the answers

Which of the following factors does NOT need to be considered when determining patient mobility needs?

The patient's favorite activities Signup and view all the answers

What is the rationale for performing hand hygiene before patient handling?

To prevent the spread of microorganisms Signup and view all the answers

What is the primary purpose of having the patient fold their arms across their chest during repositioning?

To prevent hyperextension of the neck Signup and view all the answers

Why is it important for nurses to position themselves at the patient's midsection with feet shoulder-width apart?

To lower the center of gravity and reduce injury risk Signup and view all the answers

What effect does engaging the bed mechanism have when repositioning a patient?

Makes the surface firmer for repositioning Signup and view all the answers

Which technique helps prevent back injury during the patient transfer?

Using large muscle groups and keeping the back straight Signup and view all the answers

How does the patient assisting in the move benefit the nurses?

It decreases the nurses' workload and effort required Signup and view all the answers

What is the purpose of readjusting the bed to a normal height after repositioning a patient?

To ensure safety and comfort for the patient Signup and view all the answers

What does the rocking motion utilized during patient transfer achieve?

It allows for a smooth lift with minimal exertion Signup and view all the answers

What is the benefit of having essential items and the call bell within the patient's reach after repositioning?

To promote patient independence and safety Signup and view all the answers

Study Notes

Documentation Guidelines

Wound care: Document the wound appearance, drainage, and surrounding skin condition before and after applying Montgomery straps
Dressing details: Record dressing type used, including skin protectant and barrier
Patient response: Document the pain level and patient's response to dressing care
Patient education: Include any relevant educational information for the patient and family

Safe Patient Handling

Use friction-reducing sheet for movement to minimize shearing force during repositioning
Delegate task to qualified staff, taking into account the patient's condition and needs
Consult Safe Patient Handling Algorithm in Skill 173

Moving Patient Up in Bed Procedure Steps

Assessment: Review medical record, patient's condition, mobility limitations, ability to understand directions, and weight
Hand hygiene: Perform hand hygiene and don PPE before handling patient
Patient identification: Verify patient's identity
Privacy: Close curtains and door
Bed position:
- Set bed at comfortable height
- Adjust head of the bed to flat position or as low as tolerated by patient
- Place in slight Trendelenburg position if feasible
Pillows: Remove all pillows except one at the head of the bed
Positioning: Have one nurse on each side of the bed, both side rails down
Friction-reducing sheet: Use if not already in place
Patient assistance: Encourage patient (if able) to bend legs, flatten feet, fold arms across chest, assist with lifting head
Nurse positioning: Position nurses on either side of the patient's midsection, feet spread shoulder width apart
Rocking motion: Nurses grasp sheet securely, flex their knees, tighten abdominal and gluteal muscles while keeping back straight, rock back and forth then move patient on the count of three
Post-procedure care: Assist patient to a comfortable position, adjust pillows, return bed to normal setting, raise side rails as needed, lower bed to lowest position

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Description

This quiz focuses on the essential aspects of nursing documentation, particularly in wound care and patient education. It also outlines safe patient handling techniques and procedures for moving patients in bed. Test your knowledge on these crucial nursing practices to ensure both patient safety and quality care.